BOI into the 2012 Tornado Collision over the Moray Firth
Well absolutely right, F3WMB, but that is the problem! What is the point of an Accident Investigator that cannot produce excellent SIs because it is part of a corrupt system that covers up and obscures the truth by acts of commission and omission?
We need to remember that the RAF started down this spiral of subversion and cover up by the issuing of illegal orders. Despite evidence being submitted to the RAF High Command, the RAF Provost Marshal, the Civil Police, FAIs, Coroners Inquests, Judicial Inquiries, Houses of Parliament Select Committees, SoS's, Ministers, and MPs, no VSO has ever been formally challenged with doing so, despite it being an offence in Military Law.
SIs that do not turn up all the evidence associated with an aircraft accident are part of the problem and simply ensure that avoidable accidents will simply go on happening.
The MilAAIB and MAA have to be made independent of this corrupt system and of each other if they are to do their job properly, which is to ensure that avoidable accidents are avoided in future.
We need to remember that the RAF started down this spiral of subversion and cover up by the issuing of illegal orders. Despite evidence being submitted to the RAF High Command, the RAF Provost Marshal, the Civil Police, FAIs, Coroners Inquests, Judicial Inquiries, Houses of Parliament Select Committees, SoS's, Ministers, and MPs, no VSO has ever been formally challenged with doing so, despite it being an offence in Military Law.
SIs that do not turn up all the evidence associated with an aircraft accident are part of the problem and simply ensure that avoidable accidents will simply go on happening.
The MilAAIB and MAA have to be made independent of this corrupt system and of each other if they are to do their job properly, which is to ensure that avoidable accidents are avoided in future.
Last edited by Chugalug2; 3rd Jul 2014 at 13:27. Reason: Missed out Judicial Inquiries
Fox3
I think the answer depends on the terms of reference laid down by the Scottish Crown Office (to whom submissions have already been made in this case). The Chinook case is a good example. The Sheriff was robust, totally rejecting MoD's claims. The practical difficulty is that MoD (seen to be in another country and subject to different laws) are usually allowed to judge their own case - again, they were simply permitted to ignore the Sheriff and Houses of Commons and Lords on Chinook.
With so few people caring or having the time or energy for 17 year campaigns, we can see the result. Chinook (and Nimrod, C130 etc) are too readily forgotten and we are fobbed off, yet again, with "Now we have the MAA, this can never happen again, so let's move on". The MAA is now over 4 years old and the elephant in the room remains. According to MoD, in reply to an MP, not one of its employees has ever reported airworthiness failings. That means either (a) they have failed in their legal obligation or (b) they are so inexperienced they have never worked in this domain before. There is a (c), that MoD are wrong to say this, but as of January this year they remain absolutely insistent and consistent on this matter. Either way, the current set up is unconvincing, witnessed by........
MoD/MAA and the Secy of State (Hammond) have played their hand on this one, demonstrating willingness to serially lie. For example, Hammond's December 2013 statement in the House, in reply to Angus Robertson MP, that CWS could never have been fitted on time to influence this accident, so the issue is academic. The SI of course totally contradicted this, stating categorically that it could and should have been fitted in time, and would have in all probability prevented the accident. Well done the SI - but did they know they were making career limiting statements?! And how stupid/arrogant are the MAA for allowing this to be released unredacted, knowing it contradicts Hammond. A 5 year Technology Demonstrator Programme had resulted in us being good to go in 1996, the 1998 submission actually specifying we could proceed direct to "C Model". (That is, we were one very small administrative step from Main Gate, in today's terms). Now MAA and Hammond claim that one small step would have taken over 16 years! Will Hammond withdraw? What will the same MoD source (MAA) say in their briefing when the question is asked?
I think the answer depends on the terms of reference laid down by the Scottish Crown Office (to whom submissions have already been made in this case). The Chinook case is a good example. The Sheriff was robust, totally rejecting MoD's claims. The practical difficulty is that MoD (seen to be in another country and subject to different laws) are usually allowed to judge their own case - again, they were simply permitted to ignore the Sheriff and Houses of Commons and Lords on Chinook.
With so few people caring or having the time or energy for 17 year campaigns, we can see the result. Chinook (and Nimrod, C130 etc) are too readily forgotten and we are fobbed off, yet again, with "Now we have the MAA, this can never happen again, so let's move on". The MAA is now over 4 years old and the elephant in the room remains. According to MoD, in reply to an MP, not one of its employees has ever reported airworthiness failings. That means either (a) they have failed in their legal obligation or (b) they are so inexperienced they have never worked in this domain before. There is a (c), that MoD are wrong to say this, but as of January this year they remain absolutely insistent and consistent on this matter. Either way, the current set up is unconvincing, witnessed by........
MoD/MAA and the Secy of State (Hammond) have played their hand on this one, demonstrating willingness to serially lie. For example, Hammond's December 2013 statement in the House, in reply to Angus Robertson MP, that CWS could never have been fitted on time to influence this accident, so the issue is academic. The SI of course totally contradicted this, stating categorically that it could and should have been fitted in time, and would have in all probability prevented the accident. Well done the SI - but did they know they were making career limiting statements?! And how stupid/arrogant are the MAA for allowing this to be released unredacted, knowing it contradicts Hammond. A 5 year Technology Demonstrator Programme had resulted in us being good to go in 1996, the 1998 submission actually specifying we could proceed direct to "C Model". (That is, we were one very small administrative step from Main Gate, in today's terms). Now MAA and Hammond claim that one small step would have taken over 16 years! Will Hammond withdraw? What will the same MoD source (MAA) say in their briefing when the question is asked?
Thanks for the explanation tuc. 
So it seems that despite this massive procurement organisation we've got, whether or not we get a safe aircraft with the right kit can be down to what job a junior civvy has had in the past. 
Certainly explains a lot. Seems to me you could strip half the management layers out and things would improve overnight.
So it seems that despite this massive procurement organisation we've got, whether or not we get a safe aircraft with the right kit can be down to what job a junior civvy has had in the past. Certainly explains a lot. Seems to me you could strip half the management layers out and things would improve overnight.
Last year I had the dubious pleasure of working with some junior officers in the Department for Education. They were terribly bright, and generally pleasant people who wanted to see their department make real progress; but they knew f#ck all about what goes on in real schools and did not batt an eyelid when a Minister ordered them to break the Law (suppression of free speech in this case).
Furthermore, they have a set of procedures, to which they probably offer sacrifices in secret. Consequently, they really, really do not like it when you prove to them their procedures have not, and cannot, work. Unless you hand them another procedure which does work and let them pass it off as their own 'development', in which case they quietly let you do what you like. Another option I used was to reverse engineer the formulae in their planning and monitoring spreadsheets. I managed to concoct a set of fanciful numbers which both satisfied their criteria and allowed us to basically do what we liked. Since they have little experience of reality, they accepted them.
This would seem to match Tucumseh's description of MoD/DE&S. One could, looking at the structural elements, suspect this is true of all Government Departments these days.
Furthermore, they have a set of procedures, to which they probably offer sacrifices in secret. Consequently, they really, really do not like it when you prove to them their procedures have not, and cannot, work. Unless you hand them another procedure which does work and let them pass it off as their own 'development', in which case they quietly let you do what you like. Another option I used was to reverse engineer the formulae in their planning and monitoring spreadsheets. I managed to concoct a set of fanciful numbers which both satisfied their criteria and allowed us to basically do what we liked. Since they have little experience of reality, they accepted them.
This would seem to match Tucumseh's description of MoD/DE&S. One could, looking at the structural elements, suspect this is true of all Government Departments these days.
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What is Tolerable
Forgetting about ALARP, for the moment, when the MoD/MAA and Duty Holders refer to the risk of collision as being "Tolerable" they are basing their judgement on the MAA document RA 1210. That fact is clear from the SI report.
However, RA 1201 does not give any guide lines on risk classification in the form identified by Haddon-Cave (and the CAA), but merely presents a HSE table relating to death rates. This table defines the boundary between Tolerable and Intolerable as being 1 in 1000 for the population at risk per year. No guide lines are given on how this figure should be arrived at in practice, but given that during 2012/13 we had 7 Class A near misses (each with a potential for 2 fatalities), plus 3 actual fatalities, the potential death rate must be significantly worse than the 1 in 1000 per year. In other words "Intolerable". RA 1201 advises DHs to include "near misses"
N.B. Using the H-C approach (BP 1201) and that of the CAA the collision risk is also classed as being "Intolerable"
Moving on to a term that is used in all versions of the risk matrix, that of "Remote", or the frequency of the risk. Both H-C (BP 1201) and the CAA define "remote" as being "unlikely to occur during the operational life of the fleet (1.0 E-5 to 1.0 E-6 flying hours). RA 1210 simply defines "remote" as being "Likely to occur one or more times in 10 years" no mention of flying hours. The over all collision risk is defined in the current Risk Register as Remote/Catastrophic and from a matrix places the risk at AOC 1 Gp level. However, when we consider that over the last ten years we have had 25 Class A near misses, plus one collision, the frequency should be set at the "Occasional" level (Likely to occur one or more times a year). This puts it at the door of CAS.
As it stands RA 1210 appears to be "Unfit for purpose", and the MoD/MAA and all Duty Holders (risk owners) should have a big rethink regarding their interpretation of this document. RA 1210 should be rewritten and brought into line with the real world, as failure to do so could result in future accidents and legal implication.
DV
However, RA 1201 does not give any guide lines on risk classification in the form identified by Haddon-Cave (and the CAA), but merely presents a HSE table relating to death rates. This table defines the boundary between Tolerable and Intolerable as being 1 in 1000 for the population at risk per year. No guide lines are given on how this figure should be arrived at in practice, but given that during 2012/13 we had 7 Class A near misses (each with a potential for 2 fatalities), plus 3 actual fatalities, the potential death rate must be significantly worse than the 1 in 1000 per year. In other words "Intolerable". RA 1201 advises DHs to include "near misses"
N.B. Using the H-C approach (BP 1201) and that of the CAA the collision risk is also classed as being "Intolerable"
Moving on to a term that is used in all versions of the risk matrix, that of "Remote", or the frequency of the risk. Both H-C (BP 1201) and the CAA define "remote" as being "unlikely to occur during the operational life of the fleet (1.0 E-5 to 1.0 E-6 flying hours). RA 1210 simply defines "remote" as being "Likely to occur one or more times in 10 years" no mention of flying hours. The over all collision risk is defined in the current Risk Register as Remote/Catastrophic and from a matrix places the risk at AOC 1 Gp level. However, when we consider that over the last ten years we have had 25 Class A near misses, plus one collision, the frequency should be set at the "Occasional" level (Likely to occur one or more times a year). This puts it at the door of CAS.
As it stands RA 1210 appears to be "Unfit for purpose", and the MoD/MAA and all Duty Holders (risk owners) should have a big rethink regarding their interpretation of this document. RA 1210 should be rewritten and brought into line with the real world, as failure to do so could result in future accidents and legal implication.
DV
Last edited by Distant Voice; 4th Jul 2014 at 12:53. Reason: Spelling
Below the Glidepath - not correcting
By all means identify the MoD's failings in getting a CWS solution implemented over the years, but this SI accurately and effectively identified the reasons behind this particular tragedy. There were multiple failings long before any CWS could have potentially affected the final outcome.
I'm all for pointing out the years of neglect, ignorance and malfeasance by the MoD/MAA in upholding the duty of care surrounding airworthiness, but don't conflate that fact with the assumption that every SI has been "nobbled" or lacked objectivity in any way. It does a huge disservice to those members of the SI who are as invested as anyone in preventing a reoccurrence of an entirely preventable accident.
I'm all for pointing out the years of neglect, ignorance and malfeasance by the MoD/MAA in upholding the duty of care surrounding airworthiness, but don't conflate that fact with the assumption that every SI has been "nobbled" or lacked objectivity in any way. It does a huge disservice to those members of the SI who are as invested as anyone in preventing a reoccurrence of an entirely preventable accident.
Twos In
I think you are correct about the SI panel itself. While one could legitimately argue many BoI/SI members are manifestly unsuitable for the job through lack of training, knowledge or experience, the vast majority do their best. In the same way very many "project managers" in DE&S and its predecessors were never trained to do the job, try their best, but fail to deliver because they haven't been taught the basics. (There's no one left to teach them).
But the issue I and, I believe, others have is the restrictive ToRs of these inquiries, which actively prevent them digging deeper to make sense of the evidence they hear. The result, time after time, is the reports list the same old recommendations. And the penny never drops that all they are doing is recommending application of mandated regs or plain common sense. The Airworthiness Review Teams of the 90s were the same. Chief Engineer Alcock specifically instructed the team leaders, through the Inspector of Flight Safety (RAF), that under no circumstances were the ARTs to go near MoD's airworthiness experts. Such directives immediately raise suspicions. Who are they designed to protect? The reports went to two people; the two with most to lose if their policies and directives became public (i.e. CE and ACAS). When they DID become public, largely by luck (the by now elderly CHART Leader making contact), they lost the biggest case of all and retreated.
Where I believe "nobbling" has taken place is at Reviewing Officer level and above, including the MAA. It is the system, designed to prevent recurrence, that is nobbled. The result is recurring systemic failures. I cited blatant lies in this Tornado case, and this lying has been proven beyond any doubt on Chinook, Sea King ASaC (perhaps the worst yet least explored case), C130, Nimrod etc. These are, frankly, illegal acts. If the MAA were ignorant as well as incompetent it would be bad enough, but they are not ignorant of these facts. They have been presented to the MAA in the presence of Ministers, and they have done nothing.
May I suggest people read up on Tornado ZG710 (March 2003 Patriot shootdown). On the face of it a different set of circumstances, but the root failures are EXACTLY the same. That is, predictable, predicted, notified and ignored. Any reasonable person would ask just what was going on in that area of MoD.
So who has the best interests of aircrew at heart? And who lies to protect the guilty? I know who I'd want on my side.
Fox3 & Dervish
In this particular case I would not be so critical of DE&S/DPA/PE. Their role was to support OR with advice and assistance. As I said, the solution was at a lower level, and procurers should never have been presented with the problem. However, when it became a problem, the procurers would have known it was coming but clearly didn't do very much. We need to know why, yet neither the SI nor the MAA go there. This supine acceptance of critical safety failures is entirely typical of what was going on in Haddon-Cave's "Golden Period" and continues today.
I agree with stripping half the management layers!
I think you are correct about the SI panel itself. While one could legitimately argue many BoI/SI members are manifestly unsuitable for the job through lack of training, knowledge or experience, the vast majority do their best. In the same way very many "project managers" in DE&S and its predecessors were never trained to do the job, try their best, but fail to deliver because they haven't been taught the basics. (There's no one left to teach them).
But the issue I and, I believe, others have is the restrictive ToRs of these inquiries, which actively prevent them digging deeper to make sense of the evidence they hear. The result, time after time, is the reports list the same old recommendations. And the penny never drops that all they are doing is recommending application of mandated regs or plain common sense. The Airworthiness Review Teams of the 90s were the same. Chief Engineer Alcock specifically instructed the team leaders, through the Inspector of Flight Safety (RAF), that under no circumstances were the ARTs to go near MoD's airworthiness experts. Such directives immediately raise suspicions. Who are they designed to protect? The reports went to two people; the two with most to lose if their policies and directives became public (i.e. CE and ACAS). When they DID become public, largely by luck (the by now elderly CHART Leader making contact), they lost the biggest case of all and retreated.
Where I believe "nobbling" has taken place is at Reviewing Officer level and above, including the MAA. It is the system, designed to prevent recurrence, that is nobbled. The result is recurring systemic failures. I cited blatant lies in this Tornado case, and this lying has been proven beyond any doubt on Chinook, Sea King ASaC (perhaps the worst yet least explored case), C130, Nimrod etc. These are, frankly, illegal acts. If the MAA were ignorant as well as incompetent it would be bad enough, but they are not ignorant of these facts. They have been presented to the MAA in the presence of Ministers, and they have done nothing.
May I suggest people read up on Tornado ZG710 (March 2003 Patriot shootdown). On the face of it a different set of circumstances, but the root failures are EXACTLY the same. That is, predictable, predicted, notified and ignored. Any reasonable person would ask just what was going on in that area of MoD.
So who has the best interests of aircrew at heart? And who lies to protect the guilty? I know who I'd want on my side.
Fox3 & Dervish
In this particular case I would not be so critical of DE&S/DPA/PE. Their role was to support OR with advice and assistance. As I said, the solution was at a lower level, and procurers should never have been presented with the problem. However, when it became a problem, the procurers would have known it was coming but clearly didn't do very much. We need to know why, yet neither the SI nor the MAA go there. This supine acceptance of critical safety failures is entirely typical of what was going on in Haddon-Cave's "Golden Period" and continues today.
I agree with stripping half the management layers!
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Whilst I commend the comprehensive in depth knowledge of many people's knowledge of historical procurement processes, I do continue to get frustrated at the continual inference that so very many people are in on an enormous conspiracy to nobble every SI ever produced. Military aviation safety is full of very busy, well trained and experienced people working hard to look to the future and do their best. Whilst some people on these forums might have been around when decisions were made 20+ years ago, most of the key decision makers in MoD today would have been barely out of university or training. I don't disagree with many of the comments on these forums but how about debating how a performance based approach to safety might be applied to the modern military rather than criticising decisions made so many years ago.
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But as I pointed out, the people of today are not responsible for the failings of their predecessors. They can only look to the future and do their best. The continued inference that the current incumbents of every position in military aviation safety are all are either incompetent or liars does a large number of very decent people a huge disservice.
OAP, precisely! The reason why the events of 30+ years ago (tff!) are so important is that a decision was made at the highest level to subvert Air Safety for short term gain. As a result those with airworthiness delegation were ordered to suborn the regs, and thus be personally compromised thereafter, or to go. The regs themselves were progressively scrapped so that those inexperienced and untrained people who replaced those that were gone had no means of implementing the regs even if they wished to. Hence Mk10 seats lacked a Safety Case, IFFs lacked failure warnings, grossly unairworthy aircraft were illegally Released to Service, and many people died.
So that was then and now is now, but the system still remains broken as tuc states, the MAA is using unrealistic Regs, as DV states, and people go on dying!
TFF, if those of today are hurt by these home truths I am truly sorry, but hurt feelings are secondary to avoidable deaths. No-one is blaming those who produced this SI. They were deceived by omission and commission, just as have been Coroners, Sheriffs, Ministers, and Parliament.
It is I that said that it was nobbled and I stand by that, because every SI is nobbled before a Board is even convened let alone deliberating. As tuc says, the system is failed, the system is partial, the system is dysfunctional. It should be saving lives, it is saving backsides instead.
Unless and until the MAAIB is free of the MAA and MOD, SIs will continue to be nobbled. That is the bitter truth, unpalatable though it be.
So that was then and now is now, but the system still remains broken as tuc states, the MAA is using unrealistic Regs, as DV states, and people go on dying!
TFF, if those of today are hurt by these home truths I am truly sorry, but hurt feelings are secondary to avoidable deaths. No-one is blaming those who produced this SI. They were deceived by omission and commission, just as have been Coroners, Sheriffs, Ministers, and Parliament.
It is I that said that it was nobbled and I stand by that, because every SI is nobbled before a Board is even convened let alone deliberating. As tuc says, the system is failed, the system is partial, the system is dysfunctional. It should be saving lives, it is saving backsides instead.
Unless and until the MAAIB is free of the MAA and MOD, SIs will continue to be nobbled. That is the bitter truth, unpalatable though it be.
But as I pointed out, the people of today are not responsible for the failings of their predecessors.
They can only look to the future and do their best.
The continued inference that the current incumbents of every position in military aviation safety are all are either incompetent or liars does a large number of very decent people a huge disservice.
In many ways, misleading by omission is even worse than lying. May I offer a simple example in this case? The SI Panel recommends better management of MF760 (Narrative Fault Reports). (The report is poorly worded, making me uncertain if they understand). The progression, to a satisfactory conclusion, of MF760s is a CORE component of Maintaining the Build Standard, which is a mandatory pre-requisite to a valid Safety Case and, hence, Release to Service. Not having such an audit trail, which MUST be a quite deliberate and conscious act of "savings at the expense of safety", would be your top risk.
As I said above, the MAA have studiously avoided mentioning this direct link. Why?
Very few in the past 20 years understood this simple process, because it was effectively cancelled under Chief Engineer Alcock. But that loss of Corporate Knowledge is no longer an excuse following the evidence to Lord Philip and Haddon-Cave. What the SI report should do is put a simple footnote to this effect against this recommendation, to demonstrate they actually appreciate the full impact of what, at the moment, looks like a throw-away statement. In fact, it is in many ways the most serious of them all, because it clearly reveals no lessons have been learned from the host of other accidents that shared this systemic failing. (See the Rivet Joint and Spry threads - MoD get the basic definitions worng, proving my point better than I ever could).
As I said above - compartmentalisation. What will happen in this Tornado case? Tornado will change their MF760 procedures slightly (yet still ignore mandated policy, or more likely continue in total ignorance of it), but what is needed is a policy decision to rid us of Alcock's legacy. That is, properly fund the subject (valid Safety Cases) pan-MoD. You'd be surprised at how little it costs compared to lives lost; as well as equipment. So, SI recommendations should also carry a statement of applicability. Is it isolated, or systemic? Having to answer this simple question would improve competences immeasurably. And it would almost certainly reveal holes in the education of the Panel's engineer!
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Ministerial Statement
It is reported that the law firm acting on behalf of the families have comfirmed that the Ministry of Defence will accept liabilty for the mid-air collision. What a pity that this could not have been mentioned in the Ministerial Statement issued prior to the release of the SI report.
DV
DV
, is it because illegality in the past is still unrighted wrong today?
But their best demonstrably isn't good enough if they don't understand and accept history.
Not sure who made this accusation
SIs will continue to be nobbled. That is the bitter truth, unpalatable though it be.
Someone, many years ago, decided that the emerging technology of CWS was not required on the Tornado, or they decided that something else was more important and given only a finite pot of money that was this year's priority. So Tornado might have got a new DAS or a new weapon or better GPS because the reality is there is only so much money and other systems, at that point in time, were deemed to be more important.
Why not get together, build a case, formally complain to the police, or the serious crime agency, or to Defence Internal Audit. Write a book, go to the press, make a film, but stop criticizing others who are doing their best, within their terms of reference, to investigate the circumstances surrounding an incident and most certainly have not been "nobbled" (hamstrung maybe).
Roland
You defend the BoIs and VSOs because allegedly they kept to their terms of reference. Within a very narrow view this is probably true of the BoI members. But what about, as tuc says, their legal obligations and duty of care? Do they not have greater weight? I'm not having a pop, just asking a logical question. I had very low level delegation at one time and I know my letter placed me under direct orders to report these things. I know the pressure we were under not to say anything if a senior officer or policy was involved. Your post reminds me of that pressure.
What the "usual suspects" are pushing for here is a transparent and honest system. Why are you agin this?
You defend the BoIs and VSOs because allegedly they kept to their terms of reference. Within a very narrow view this is probably true of the BoI members. But what about, as tuc says, their legal obligations and duty of care? Do they not have greater weight? I'm not having a pop, just asking a logical question. I had very low level delegation at one time and I know my letter placed me under direct orders to report these things. I know the pressure we were under not to say anything if a senior officer or policy was involved. Your post reminds me of that pressure.
What the "usual suspects" are pushing for here is a transparent and honest system. Why are you agin this?
RP, when all else fails play the man instead of the ball, eh?
When this campaign was in its infancy we were accused of attacking hard working honourable Very Senior Officers, until it became clear that the VSOs we were attacking had set out to, and succeeded in, destroying the process of providing and maintaining airworthiness in the Military Airfleets.
Now the charge is that we are attacking OR's, JO's, and SO's who are trying their best to provide for Military Air Safety, when we are not. What we are trying to point out to those prepared to listen is that the system for providing Military Air Safety, whether it be for Airworthiness Provision or Accident Investigation, is broken. That is no criticism of those stuck with the unenviable task of doing their best in dealing with that system, it is criticism of the system itself.
That is what I mean by saying that SIs are nobbled, for they are denied access to all the facts. It is the SI that is nobbled, not those who sit on its panel who, I am sure, do their level best to get to the truth. That is no way to run Air Safety, because it costs lives, money, and capability. The cost of protecting those who created this mess and those who cover for them can be counted by each and everyone of those factors.
Those that you speak on behalf of will be able to do their job, to save lives, when they are freed of such constraints and discover that the same conclusions that they come to have been discovered over and over again, only to be cast aside every time.
When this campaign was in its infancy we were accused of attacking hard working honourable Very Senior Officers, until it became clear that the VSOs we were attacking had set out to, and succeeded in, destroying the process of providing and maintaining airworthiness in the Military Airfleets.
Now the charge is that we are attacking OR's, JO's, and SO's who are trying their best to provide for Military Air Safety, when we are not. What we are trying to point out to those prepared to listen is that the system for providing Military Air Safety, whether it be for Airworthiness Provision or Accident Investigation, is broken. That is no criticism of those stuck with the unenviable task of doing their best in dealing with that system, it is criticism of the system itself.
That is what I mean by saying that SIs are nobbled, for they are denied access to all the facts. It is the SI that is nobbled, not those who sit on its panel who, I am sure, do their level best to get to the truth. That is no way to run Air Safety, because it costs lives, money, and capability. The cost of protecting those who created this mess and those who cover for them can be counted by each and everyone of those factors.
Those that you speak on behalf of will be able to do their job, to save lives, when they are freed of such constraints and discover that the same conclusions that they come to have been discovered over and over again, only to be cast aside every time.
Roland
You are of course entitled to your opinion, which I respect.
Build a Case - Done. Fully accepted by, for example, Lord Philip and Haddon-Cave (although the latter changed the start date from 1988 to 1998, an act that actively protected certain VSOs). This act is a repetitive feature of most reports.
Formally complain to Police - Done. Thames Valley Constabulary (2 Asst Chief Constables and Chief Constable) confirmed MoD were permitted to judge their own case, and they had no authority. Although one Asst CC was more than ambiguous, offering 3 very different and contradictory reasons, that amounted to "We've been told we don't want to know". The Independent Police Complaints Commission has demonstrated its independence by inviting the same Asst CC to judge her own case. She has confirmed her independent inquiry has ruled in her favour. Civil Service Commissioners and Parliamentary Ombudsman said the same.
Defence Internal Audit - Done. DIA ruled in my favour. MoD took no action and scrapped the report. (Source - FoI reply. The person who took no action was the 2 Star with management oversight responsibility for Chinook, Nimrod......., supported by his 4 Star). There were 19 recommendations. Implementing #13, for example, would have mitigated most of the problems I air here.
Write a Book - Well, the main submission to Lord Philip, which he read and fully accepted, was about 270 pages. It subsumed the main submission to Haddon-Cave. Various supplementary submissions were made, as his original deadline was extended for 6 months after CHART and its implications were revealed.
Go to the press - Done. They tend to listen to MoD when they say it is an isolated case and can never happen again; and when it does they conveniently ignore it because they are seen to be complicit. However, the media (BBC) were excellent during the Philip Inquiry, being instrumental in exposing the lies retired VSOs and civilians told about, for example, CHART. For example, Alcock claimed it had nothing to do with Chinook Mk2, when Mk2 was mentioned over 370 times. He claimed Mk2 was not mentioned in the Team's TORs, but it was. He claimed the recommendations were implemented, but they weren't - they were repeated ad nauseum in later ARTs. None of this is opinion - Lord Philip was most impressed by the fact they were easily disproved by simply submitting the evidence Alcock claimed didn't exist. A recurring theme.
Make a film - Ah, got me there. I don't have the wherewithall. However, I (along with another ppruner) have taken part in a 2 hour programme about MoK when all the above was discussed in greater detail than the usual 10 second soundbite permits. MoD declined to take part.
Yes, you are right, "hamstrung" is a better word in most cases. That is the point I make. Their ToRs are too restrictive. I said that. Dervish also makes the valid point about obligations and duty of care. Yes, I believe they take precedence at all times over SI/BoI ToRs. If the members are discouraged from speaking, or they do speak and a report is amended (e.g. MoK) or destroyed and a statement made it doesn't exist (ASaC), then that is definitely "nobbling".
Hope this clarifies my position.
You are of course entitled to your opinion, which I respect.
Why not get together, build a case, formally complain to the police, or the serious crime agency, or to Defence Internal Audit. Write a book, go to the press, make a film, but stop criticizing others who are doing their best, within their terms of reference, to investigate the circumstances surrounding an incident and most certainly have not been "nobbled" (hamstrung maybe).
Build a Case - Done. Fully accepted by, for example, Lord Philip and Haddon-Cave (although the latter changed the start date from 1988 to 1998, an act that actively protected certain VSOs). This act is a repetitive feature of most reports.
Formally complain to Police - Done. Thames Valley Constabulary (2 Asst Chief Constables and Chief Constable) confirmed MoD were permitted to judge their own case, and they had no authority. Although one Asst CC was more than ambiguous, offering 3 very different and contradictory reasons, that amounted to "We've been told we don't want to know". The Independent Police Complaints Commission has demonstrated its independence by inviting the same Asst CC to judge her own case. She has confirmed her independent inquiry has ruled in her favour. Civil Service Commissioners and Parliamentary Ombudsman said the same.
Defence Internal Audit - Done. DIA ruled in my favour. MoD took no action and scrapped the report. (Source - FoI reply. The person who took no action was the 2 Star with management oversight responsibility for Chinook, Nimrod......., supported by his 4 Star). There were 19 recommendations. Implementing #13, for example, would have mitigated most of the problems I air here.
Write a Book - Well, the main submission to Lord Philip, which he read and fully accepted, was about 270 pages. It subsumed the main submission to Haddon-Cave. Various supplementary submissions were made, as his original deadline was extended for 6 months after CHART and its implications were revealed.
Go to the press - Done. They tend to listen to MoD when they say it is an isolated case and can never happen again; and when it does they conveniently ignore it because they are seen to be complicit. However, the media (BBC) were excellent during the Philip Inquiry, being instrumental in exposing the lies retired VSOs and civilians told about, for example, CHART. For example, Alcock claimed it had nothing to do with Chinook Mk2, when Mk2 was mentioned over 370 times. He claimed Mk2 was not mentioned in the Team's TORs, but it was. He claimed the recommendations were implemented, but they weren't - they were repeated ad nauseum in later ARTs. None of this is opinion - Lord Philip was most impressed by the fact they were easily disproved by simply submitting the evidence Alcock claimed didn't exist. A recurring theme.
Make a film - Ah, got me there. I don't have the wherewithall. However, I (along with another ppruner) have taken part in a 2 hour programme about MoK when all the above was discussed in greater detail than the usual 10 second soundbite permits. MoD declined to take part.
Yes, you are right, "hamstrung" is a better word in most cases. That is the point I make. Their ToRs are too restrictive. I said that. Dervish also makes the valid point about obligations and duty of care. Yes, I believe they take precedence at all times over SI/BoI ToRs. If the members are discouraged from speaking, or they do speak and a report is amended (e.g. MoK) or destroyed and a statement made it doesn't exist (ASaC), then that is definitely "nobbling".
Hope this clarifies my position.
RP, when all else fails play the man instead of the ball, eh?
Roland has never told us what it is he's unhappy with. Does he want the status quo or our aircraft to be safe? Or neither? (Both is impossible.)
Tuc has told us what he's done to present his case. Over to you Roland. How did you get on when you did the same.
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Risk Duty Holder
Notwithstanding the failure to fit a collision warning system in Tornado GR4 this accident could have been prevented by the Operational Duty Holder (AVM Stuart David Atha - AOC 1Group).
As ODH, and owner of the risk, he declared the risk to be Tolerable and ALARP, knowing full well that between 2008 and 2011 there had been eight Tornado Class A near misses, at least two being Tornado against Tornado. These incidents had the potential to create twenty fatalities amongst Tornado crews. It is hoped that AVM Atha will be called as a witness at any future Fatal Accident Inquiry in order to justify his decision.
According to MRP RA 1020 DHs slould cease routine aviation operations if RtL are identified that are not at least Tolerable and ALARP.
DV
As ODH, and owner of the risk, he declared the risk to be Tolerable and ALARP, knowing full well that between 2008 and 2011 there had been eight Tornado Class A near misses, at least two being Tornado against Tornado. These incidents had the potential to create twenty fatalities amongst Tornado crews. It is hoped that AVM Atha will be called as a witness at any future Fatal Accident Inquiry in order to justify his decision.
According to MRP RA 1020 DHs slould cease routine aviation operations if RtL are identified that are not at least Tolerable and ALARP.
DV
Last edited by Distant Voice; 7th Jul 2014 at 14:19. Reason: spelling