HC and his Safety Culture...
Yes, I read that at the time. I don't want to get into personalities, as the report acknowledges MAA's difficulties with SQEP (but, like H-C, studiously avoids the reason, which gets you VERY close to the root failures and culprits), but if you map the H-C recommendations against MAA actions there is very little correlation. Nor, with respect, do any of the named MoD staff in the report (with one possible exception) have any experience in the practical implementation of the regulations designed to prevent the failures in the first place. That is not their fault - the majority are simply not trained or employed to do the job, in the same way I'm not trained to be a pilot. The nett result is most confuse airworthiness, serviceability and fitness for purpose; talking mainly of the last. You can see this in the very basic errors in many MAA documents, that no MoD Technical Agency would be expected to make. These errors mean some important regs disappear off at a tangent, leading to (e.g.) the observations above by Crab. The simple example I always use is getting the definition of the process that maintains the safety case wrong: which, after all, was what H-C spent 580-odd pages on. In fact, the definition used is essentially the same as DPP(PM) used in 1993 when drafting the ill-fated CDPIs, which were (in part) to replace Controller Aircraft Instructions. The problem of course was, the perfectly good CAIs were cancelled, but so were the CDPIs when they were exposed as crap (by the same Directorate in charge of Chinook, ironically; which in turn illustrates the state of play long before H-C's 1998 nonsense). That left very little advice for new staff, compounded in 1996 by CDP's decision just to do away with engineering staffs. Sorry, I just see all these links because I've had to deal with the fallout. The MAA have a difficult task, not of their own making, and I wouldn't like to work there. Not because I couldn't do the job. But because I wouldn't be allowed to to the job properly.
Tuc:-
Which just about sums up the farce that is UK Military Air Regulation in 2016. This forum will spawn many more such threads as the Air Cadets Grounded one as the dysfunctional state of UK Military Airworthiness bites ever deeper.
The MAA won't do anything because it can't, for the very reason that tucumseh points to, ie that it is not independent of the MOD. It is for that reason that it embraces Haddon-Cave and its false start date of 1998. The wheels fell off a decade before then, thanks to the illegal acts of certain VSOs. It is to protect them that H-C rewrote history, and why the MAA is founded on a false prospectus. It lacks knowledge and the will to reveal the truth, and contents itself in trying to reinvent the wheel, or in this case perfectly good regulations that merely need to be enforced, if only it knew how.
The Royal Air Force has to bite the bullet and acknowledge that its aircraft, and hence its fighting ability, are badly compromised. The only way to start the process of rebuilding its airworthiness is to face the truth and start afresh by making its regulator and air accident investigator independent of the MOD and of each other. What it does about its VSOs that reduced it to this parlous state is for it to decide, but if it goes on protecting them it cannot regain airworthiness. It must choose, and choose wisely.
The MAA have a difficult task, not of their own making, and I wouldn't like to work there. Not because I couldn't do the job. But because I wouldn't be allowed to to the job properly.
The MAA won't do anything because it can't, for the very reason that tucumseh points to, ie that it is not independent of the MOD. It is for that reason that it embraces Haddon-Cave and its false start date of 1998. The wheels fell off a decade before then, thanks to the illegal acts of certain VSOs. It is to protect them that H-C rewrote history, and why the MAA is founded on a false prospectus. It lacks knowledge and the will to reveal the truth, and contents itself in trying to reinvent the wheel, or in this case perfectly good regulations that merely need to be enforced, if only it knew how.
The Royal Air Force has to bite the bullet and acknowledge that its aircraft, and hence its fighting ability, are badly compromised. The only way to start the process of rebuilding its airworthiness is to face the truth and start afresh by making its regulator and air accident investigator independent of the MOD and of each other. What it does about its VSOs that reduced it to this parlous state is for it to decide, but if it goes on protecting them it cannot regain airworthiness. It must choose, and choose wisely.
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Tuc, I've observed examples of many of the issues you note, but from my personal perspective, I always come back to the issue of competence (or call it SQEP if we must). The past and present members of the MAA I've met aren't on the whole incompetent neither are they unaware of some of the problems of what they're trying to achieve.
When you look at the civil regulatory approach, its hard not to be slightly impressed by the degree of success it achieves. It isn't perfect by any means but it works well 99% of the time. There were those who hoped that transforming the military approach to take advantage of the best of the civil system, would result in safer operations and far better performance; I was one of those. For a few years the UK MAA have been working with most of their other European equivalents (27 of them) to develop a military regulatory framework based on the principles of the EASA approach. In my eyes the effort has been remarkably successful due in no small part to the leadership shown by the UK MAA.
Most of the nations involved are now at various stages in the implementation of the new framework and the UK MAA is one of these. One of the main principles of the civil system is the emphasis on competent organisations and individuals when it comes to authority on matters of airworthiness. Unfortunately, when it's come to implementation, the leadership of the UK MAA seem to have been swayed by the consideration of what might happen in times of conflict. They could only rely on MOD staff and Service Operators therefore all authority must rest with 'Crown Servants' whether technically competent or not. When challenged on this, the standard response seems to be, well they'll just have to get competent then. I can't help thinking that this will in time just lead to "HC, the sequel".
EAP
When you look at the civil regulatory approach, its hard not to be slightly impressed by the degree of success it achieves. It isn't perfect by any means but it works well 99% of the time. There were those who hoped that transforming the military approach to take advantage of the best of the civil system, would result in safer operations and far better performance; I was one of those. For a few years the UK MAA have been working with most of their other European equivalents (27 of them) to develop a military regulatory framework based on the principles of the EASA approach. In my eyes the effort has been remarkably successful due in no small part to the leadership shown by the UK MAA.
Most of the nations involved are now at various stages in the implementation of the new framework and the UK MAA is one of these. One of the main principles of the civil system is the emphasis on competent organisations and individuals when it comes to authority on matters of airworthiness. Unfortunately, when it's come to implementation, the leadership of the UK MAA seem to have been swayed by the consideration of what might happen in times of conflict. They could only rely on MOD staff and Service Operators therefore all authority must rest with 'Crown Servants' whether technically competent or not. When challenged on this, the standard response seems to be, well they'll just have to get competent then. I can't help thinking that this will in time just lead to "HC, the sequel".
EAP
...but you won't get competent people 'In Post' if you keep moving them around from front line to back-office!!
Tuc is right. There is a need for 'specialists', not merely competent or suitably qualified temps. A three week course and two or three years in post won't cut the mustard. The MAA needs career people, not transient people.
Tuc is right. There is a need for 'specialists', not merely competent or suitably qualified temps. A three week course and two or three years in post won't cut the mustard. The MAA needs career people, not transient people.
EAP86
Thank you for your considered reply. I think we are in agreement. The point you make;
echoes mine. This is the fitness for purpose argument. There is (seemingly) little understanding that one must first attain airworthiness, and so by definition have a robust process for maintaining airworthiness, before an aircraft is ever in theatre. Airworthiness is a pre-requisite to being in a position of having to make a FFP decision.
Companies like Westland tend to do most of the "attaining" bit very well. MoD has cancelled its only mandated Def Stan setting out the procedures for "maintaining" and no longer teaches the subject. (And because we have sold our workshops, there are no apprentices to teach). Many at the top consider it a waste of money - hence the savings at the expense of safety. It follows the FFP decision at front line cannot be a truly informed one, because he baseline is missing, or at best a moving feast. There is a honking great black hole in the middle.
That is my simplistic explanation, but it is clear where the gap is. It was identified in the late 80s by MoD auditors. It was reiterated umpteen times by Director of Flight Safety between 1992 and 1998. By 2000 most had just given up, and airworthiness depended largely on companies ignoring their contract and instead implementing regulations.
Rigga is right about SQEP/experience. Why is a 2 year post acceptable now, when an unbroken 10-15 years was required before? That is dumbing down. The one thing I'd say about the MAA though - they seem to have taken onboard the root cause of a number of fatal accidents - non-technical staffs being allowed to self-delegate airworthiness authority. I'd say that is their biggest success so far, but I don't like the fact that those who did, and caused so many deaths, are still in post in MoD's upper echelons. It would seem the MAA has no retrospective powers, so let us hope these people have the decency not to set foot in an aircraft project office again. 13th anniversary of two of the examples next week (22nd).
Thank you for your considered reply. I think we are in agreement. The point you make;
UK MAA seem to have been swayed by the consideration of what might happen in times of conflict
Companies like Westland tend to do most of the "attaining" bit very well. MoD has cancelled its only mandated Def Stan setting out the procedures for "maintaining" and no longer teaches the subject. (And because we have sold our workshops, there are no apprentices to teach). Many at the top consider it a waste of money - hence the savings at the expense of safety. It follows the FFP decision at front line cannot be a truly informed one, because he baseline is missing, or at best a moving feast. There is a honking great black hole in the middle.
That is my simplistic explanation, but it is clear where the gap is. It was identified in the late 80s by MoD auditors. It was reiterated umpteen times by Director of Flight Safety between 1992 and 1998. By 2000 most had just given up, and airworthiness depended largely on companies ignoring their contract and instead implementing regulations.
Rigga is right about SQEP/experience. Why is a 2 year post acceptable now, when an unbroken 10-15 years was required before? That is dumbing down. The one thing I'd say about the MAA though - they seem to have taken onboard the root cause of a number of fatal accidents - non-technical staffs being allowed to self-delegate airworthiness authority. I'd say that is their biggest success so far, but I don't like the fact that those who did, and caused so many deaths, are still in post in MoD's upper echelons. It would seem the MAA has no retrospective powers, so let us hope these people have the decency not to set foot in an aircraft project office again. 13th anniversary of two of the examples next week (22nd).
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Tuc, Rigga, agreed!
When I first encountered the MOD in RTO offices many years ago, I was a little in awe at their expertise. Likewise those staffing the old MOD PE Project Offices; everyone knew their stuff. However that was a long time ago and the likelihood that the MOD will go back to a system that assured a steady supply of competent people for all aspects of airworthiness is vanishingly small. If the will was there, I think it could be achieved in the field of continuing airworthiness if only because this is a key area for successful operations and it just needs time. As regards the field of initial/design airworthiness, I suspect that bird has flown and I doubt that the will to recover properly exists; I'm not even sure that the gap to be bridged is that well understood.
For many years, civil regulators have obtained competent resource from the relevant sectors of industry. 'Poacher turned gamekeeper' is alive and well. Similar options aren't easily available to the MOD and the perception that they have to retain authorities in house eliminates perhaps the only alternative viable solution.
Its interesting that over the last few years the French military regulators, DGA & DSAE, have adopted the civil model and have allowed authorities such as the Type Certificate Holder (and the relevant obligations) to reside outside of their MOD staff. I can't imagine the UK MAA giving this further consideration until the current model has been shown to be lacking; 10 years, say?
EAP
When I first encountered the MOD in RTO offices many years ago, I was a little in awe at their expertise. Likewise those staffing the old MOD PE Project Offices; everyone knew their stuff. However that was a long time ago and the likelihood that the MOD will go back to a system that assured a steady supply of competent people for all aspects of airworthiness is vanishingly small. If the will was there, I think it could be achieved in the field of continuing airworthiness if only because this is a key area for successful operations and it just needs time. As regards the field of initial/design airworthiness, I suspect that bird has flown and I doubt that the will to recover properly exists; I'm not even sure that the gap to be bridged is that well understood.
For many years, civil regulators have obtained competent resource from the relevant sectors of industry. 'Poacher turned gamekeeper' is alive and well. Similar options aren't easily available to the MOD and the perception that they have to retain authorities in house eliminates perhaps the only alternative viable solution.
Its interesting that over the last few years the French military regulators, DGA & DSAE, have adopted the civil model and have allowed authorities such as the Type Certificate Holder (and the relevant obligations) to reside outside of their MOD staff. I can't imagine the UK MAA giving this further consideration until the current model has been shown to be lacking; 10 years, say?
EAP
EAP86. Well said. I think this an opportune time to remind us of the events behind the two accidents I mentioned that occurred on 22 March 2003.
Sea King – The BoI’s 3 main contributory factors were predictable, and predicted in late 1994. Mitigation plans were drawn up, properly approved and fully funded (one of them was nil cost, the other two mandated policy and funded anyway). Almost immediately (December 1994), DOR(Sea) stated the nil cost one was not to be implemented. I know this, because I was writing the specs that had to be amended. This created a huge difference in form, fit, function and use between AEW Mk2 and what became ASaC Mk7, and is in part what forced the change of Mark number. While the spec reflected the OR decision, the design contract asked that both designs be undertaken, as it was assumed common sense would prevail. It didn’t.
Of the other two, one contract was cancelled in 1998, without replacement, by a non-technical official who had self-delegated technical and airworthiness authority. That is, he deemed the risk not to exist at all, despite the world and its dog saying it did. The last was cancelled by the same official in 2000. This was a safety design issue and he directed that mandated design regs be ignored.
In risk management terms the 3 main defences in depth against the risk (collision) were torn down and cast aside, without replacement; leaving the “accident trajectory” unimpeded. But there was a final defensive barrier to the RN seeing this unsafe build standard – the Critical Design Review. The same official paid the contract milestone for the CDR a week early, then waived the CDR. Boscombe’s formal complaint refers to outstanding safety case issues and critical safety mods. That is, the work remained to be done, but the money was gone. Even so, and with the programme manager’s support, Westland refused to obey the illegal instruction to ignore the regs, as they always do. The official then took it out of Westlands and the PMs hands, sent in an MoD working party and modified the aircraft with an unapproved and unsafe mod. The first trials aircraft was at the safe build standard, the remainder not. MoD denies this, despite pictorial evidence taken by Westland (who aren’t stupid and know when to gather evidence to defend future actions).
What I have described is fraud. It was actively concealed from the BoI and Coroner. The investigation it was notified was halted in February 2004, and MoD now deny it took place despite the evidence submissions being freely available.
Tornado ZG710 – The main engineering contributory factor noted by the BoI, and which in the opinion of the senior Reviewing Officer would have prevented the accident, was notified by Boscombe in 1998; and rejected by the same 2 Star who ignored the above ASaC issues. (Same person as Nimrod, Chinook, Lynx….). This was upheld by the same 4 Star, CDP, in 2001. Both in written rulings, on numerous occasions following appeals. In 2002 a further 2 Star, XD5, also rejected the recommendation for a fleet inspection, which would have revealed the non-compliance with design regs. His Military Advisor, a Major in the Royal Scots, went to great lengths to fight the aircrews’ side, to no avail. That an infantry officer had to do this is a terrible indictment. The same official as above was involved, telling the project office to ignore the specialist engineering advice from Boscombe and aircraft project managers. There was a conscious decision to render the aircraft vulnerable to friendly fire.
I was going to ask what the MAA has done that would have prevented this. But I know the answer, because they have consistently supported the decisions; including briefing Ministers against the specialist engineer who identified and notified all the above risks, on both aircraft. If they really wanted to, they might, just might, make a 2 Star think twice. But as they are not independent I suggest they will continue to support 4 Star and Ministerial decisions that what I describe does not constitute “wrongdoing”. I’m afraid those are the hard, verifiable facts. Of the 9 dead, I knew 3 very well, so feel I have a small personal interest. I know the mother of one, to whom I spoke only the other day, remains utterly distraught, especially at this time of year. She can accept her son died in action. It is the lies and deceit by MoD she cannot bear. The outright lie by a senior RN officer that mandated design regulations are merely “recommendations” and can be ignored at will. JSP553, Military Airworthiness Regulations. The clue is in the name.
Front line should never hear of these attaining and maintaining problems. But as matters stand, the root problem has been ignored and operational commanders have been told to deal with it. That is abrogation on a grand scale. Show me an operational commander who has direct influence over any of the above.
Sea King – The BoI’s 3 main contributory factors were predictable, and predicted in late 1994. Mitigation plans were drawn up, properly approved and fully funded (one of them was nil cost, the other two mandated policy and funded anyway). Almost immediately (December 1994), DOR(Sea) stated the nil cost one was not to be implemented. I know this, because I was writing the specs that had to be amended. This created a huge difference in form, fit, function and use between AEW Mk2 and what became ASaC Mk7, and is in part what forced the change of Mark number. While the spec reflected the OR decision, the design contract asked that both designs be undertaken, as it was assumed common sense would prevail. It didn’t.
Of the other two, one contract was cancelled in 1998, without replacement, by a non-technical official who had self-delegated technical and airworthiness authority. That is, he deemed the risk not to exist at all, despite the world and its dog saying it did. The last was cancelled by the same official in 2000. This was a safety design issue and he directed that mandated design regs be ignored.
In risk management terms the 3 main defences in depth against the risk (collision) were torn down and cast aside, without replacement; leaving the “accident trajectory” unimpeded. But there was a final defensive barrier to the RN seeing this unsafe build standard – the Critical Design Review. The same official paid the contract milestone for the CDR a week early, then waived the CDR. Boscombe’s formal complaint refers to outstanding safety case issues and critical safety mods. That is, the work remained to be done, but the money was gone. Even so, and with the programme manager’s support, Westland refused to obey the illegal instruction to ignore the regs, as they always do. The official then took it out of Westlands and the PMs hands, sent in an MoD working party and modified the aircraft with an unapproved and unsafe mod. The first trials aircraft was at the safe build standard, the remainder not. MoD denies this, despite pictorial evidence taken by Westland (who aren’t stupid and know when to gather evidence to defend future actions).
What I have described is fraud. It was actively concealed from the BoI and Coroner. The investigation it was notified was halted in February 2004, and MoD now deny it took place despite the evidence submissions being freely available.
Tornado ZG710 – The main engineering contributory factor noted by the BoI, and which in the opinion of the senior Reviewing Officer would have prevented the accident, was notified by Boscombe in 1998; and rejected by the same 2 Star who ignored the above ASaC issues. (Same person as Nimrod, Chinook, Lynx….). This was upheld by the same 4 Star, CDP, in 2001. Both in written rulings, on numerous occasions following appeals. In 2002 a further 2 Star, XD5, also rejected the recommendation for a fleet inspection, which would have revealed the non-compliance with design regs. His Military Advisor, a Major in the Royal Scots, went to great lengths to fight the aircrews’ side, to no avail. That an infantry officer had to do this is a terrible indictment. The same official as above was involved, telling the project office to ignore the specialist engineering advice from Boscombe and aircraft project managers. There was a conscious decision to render the aircraft vulnerable to friendly fire.
I was going to ask what the MAA has done that would have prevented this. But I know the answer, because they have consistently supported the decisions; including briefing Ministers against the specialist engineer who identified and notified all the above risks, on both aircraft. If they really wanted to, they might, just might, make a 2 Star think twice. But as they are not independent I suggest they will continue to support 4 Star and Ministerial decisions that what I describe does not constitute “wrongdoing”. I’m afraid those are the hard, verifiable facts. Of the 9 dead, I knew 3 very well, so feel I have a small personal interest. I know the mother of one, to whom I spoke only the other day, remains utterly distraught, especially at this time of year. She can accept her son died in action. It is the lies and deceit by MoD she cannot bear. The outright lie by a senior RN officer that mandated design regulations are merely “recommendations” and can be ignored at will. JSP553, Military Airworthiness Regulations. The clue is in the name.
Front line should never hear of these attaining and maintaining problems. But as matters stand, the root problem has been ignored and operational commanders have been told to deal with it. That is abrogation on a grand scale. Show me an operational commander who has direct influence over any of the above.
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Tuc, all too depressing. Its been over a year since I last had any working dealings with the MAA but if its any consolation, I believe their Duty Holder concept and the regulations surrounding it were starting bear fruit. The mandate that High Criticality risks were to be reported and escalated on a regular basis seemed to becoming a bit of a success. It was reported that VSOs at 2, 3 and 4 star levels were being alerted to the relevant risks and had to accept them at their level or escalate them further. While it could be argued that this doesn't guarantee compliance, I understand that the MAA's own audits of PTs and Commands made it less likely that issues could be concealed.
EAP
EAP
