Air Safety Implications?
 

Aviation safety suffers further setback after Helios conviction - {Travel Daily News}

I wonder what the MAA will make of this and if it will have any implications on our 'Just Culture'?

Not good.

Unbelievable, if the article is correct.

You'd like to think EASA (which Greece are a member of) should say something about this - many basic things wrong here. I could think of several ways they could apply pressure, if the will was there.

The waters were muddied long ago in MoD when Director Helicopter Support, Director Helicopter Projects, Director General Air Systems 2 and the Chief of Defence Procurement all ruled that engineering and safety decisions made by engineers, within their delegated authority (and agreed to by Boscombe Down and the Aircraft Design Authority), could be overruled by non-engineers; but if anything went wrong the engineer should be blamed.

This precise scenario occurred before and after a fatal crash in 2003, and to this day the MoD maintains the engineer is to blame, despite the records showing he issued a directive to make the aircraft safe, only to be overruled.

The MAA are so busy faffing around reinventing wheels they haven’t got round to addressing this problem yet. Perhaps this Greek tragedy will give them a push.

With all rights recognised to the author but some DII users cannot link to the article:

Indeed, c-s, tuc rightly connects this Greek kangaroo court fiasco with the MOD one that has presided over the demise of UK Military Airworthiness for some 25 years. When the professionals are pushed aside, or merely choose to step aside, this is what happens. Worse still people die because the true causes of fatal air accidents are covered up by incompetence or malevolence and scapegoats blamed instead. All that will go on happening in UK Military Aviation unless and until Airworthiness Provision and Air Accident Investigation is wrested from the MOD and placed into the hands of an MAA and MAAIB, independent of the MOD and of each other. That has yet to happen.
Self Regulation Never Works and in Aviation it Kills!

I don't know quite where military flights fit in but if the legal bods believe there is a criminal/negligence case to answer, then it could get messy. (Ie Catterick)

In a purely civil world, it is not plain sailing either - in the UK, US, Can Oz etc, they employ a very British 'adversarial' legal system - ie defence v prosecution and a Judge/Jury to decide the outcome. The accident investigators are left to get on with their job and become expert witnesses for either (or both) sides.

However, in many EU states (France, Italy, Spain etc), they have the Napoleonic legal system where the investigating judge/prosecutor call the shots and can override the safety investigation. So much so, that CVRs and ADRs get taken away from accident investigators. Furthermore, the systems appear prone to a 'default' setting of prosecuting the perpetrator of the final act in the sequence - ie crews, ATC and engineers. Organisational accidents seem to be alien to them - hence the poor engineer in this Helios case.

WRT to Brit Mil, I agree with Tuc that, should an accident like the MoK or Nimrod happen tomorrow, one has to ask how good would the MAAIB and MAA perform. Would they discover and highlight the contributions made by decades of neglect of the military airworthiness system (of which H-C only scratched the surface)? If one believes they would not - perhaps because of the extant undue political and hierarchical pressures - then maybe the MAA needs to review how it does business?

What could be done to prevent the focus being solely on the final link in the chain but also, on the organisational influences (should there be any). Could the MAA be removed from the tentacles of 'undue presure'? Dunno but it should.
Because and until the contibution of systemic MoD neglect since the 1980s is finally erradicated (along with the sinister ethos of that brigade of fools of air-rank) then we run the risk of more systemic accidents but where crews, controllers and engineers risk being scapegoated like the Helios engineer.

Re Helios fall-out, one sincerely hopes that the civil unions are on the case here. But to change the very fabric of a nation's legal system? That's a big ask.

In the meantime, if you are going to crash - try not to do it in France, Italy, Spain or Greece etc!!!

You will find over the last few years there has been a swing to push more and more on the Licenced Engineer, mainly because the likes of the CAA are petrified of being sued..

I just love it that wokkamate thinks MOD has a just culture!

Actually, and despite the spin to promote a better appearance, MOD as a whole is just leaving an embrionic safety culture, which is before a learning culture, which is before a reporting culture, which is before a just culture, which is before a proactive culture.

There are very few areas civil or military that have made it to the end - in fact, I can't think of one! Shell Management, eat your heart out!

I know of one civil company that had a good reporting culture - but that was more to do with the fact that you couldn't sack the locals easily! If you know your EU employment laws you might know which country that was in?

On the bright side, some areas of MOD have made it to a reporting culture - just.

Hence my use of 'Just culture' and not Just culture - you see what I did there? :suspect:

Damn!...I was never good at spotting that.

When I was serving the FAA certainly had a very strong just culture and was pretty close to a proactive culture.....largely ruined by the top of the RAF shop insistence on the MAA which took us back towards the unjust culture of the RAF.

ps MAA would have happened whether H-C existed or not as the RAF saw it as the route to control all things air. Oops, there I go again!

Pheasant




For a number of reasons I believe this is true.


But if Haddon-Cave had published the truth, presented to him in the form of numerous reports detailing the adverse effect of the RAF Chief Engineers’ actions (or failure to act) throughout the 90s, then I’m sure the MAA wouldn’t be the offshoot of the RAF we see today. Instead he bottled it, and praised the CE, which misled and misdirected everyone who has subsequently had to deal with the fallout.



There is at least one pprune poster here who suggested such a restructuring in about 2000. He, and the rest of us, were on a hiding to nothing because this was the same period in which senior staffs had relentlessly ruled that MoD(PE) / DPA could deliver functionally unsafe aircraft; and indeed should do so if it meant saving time or money.

Looking at it from a different perspective, on a number of occasions before and after this date I was asked to chair a committee to update the only Def Stan which laid down the procedures for managing airworthiness, in particular the delivery and maintenance of Safety Cases (the main subject of Haddon-Cave’s report). The very fact I was asked demonstrates people higher up in MoD knew of the systemic failings imposed by the Chief Engineer’s regime, especially under Alcock. In 1993 the instruction had been given not to implement the mandated procedures in this Def Stan, and funding was largely withdrawn. (They remained mandated under Controller Aircraft in MoD(PE), but as funding had been transferred to AMSO, CA’s staff had no means of meeting this legal obligation. This is the crucial evidence underpinning, for example, the fact the Chinook was unairworthy in 1994).

The update never happened because my superiors refused to release me for the requisite 2/3 days a month and, 3 years ago, the Def Stan was cancelled without replacement. But in anticipation of being allowed to do the work (the request would never have been turned down pre-1993) I produced the 1st draft, and still have it. In fact, unknown to MoD (and to prove a point:E) in 2001 I used this draft as the basis of a Business Case and specification for a Cat A project (over £400M at the time), which was approved by the very people who said we shouldn’t be using it. Which simply demonstrated they knew cock all about practical implementation. A bit like MAA.

The resulting flagship contract remains current, which makes me wonder if they realise it calls up an obsolete Standard; and how do the auditors validate and verify the contract documentation, or the MoD demonstrate they are current and maintained? They (MAA) clearly don't realise this contract exists, or else they'd have used it as a template for the work they've employed scores of consultants to do for the last 2 years.

Tuc,

An absolutely outstanding post. BZ.

This thread has highlighted a few important areas. First, just culture.

The FAA had (and still does have) a very solid Flight Safety culture and organisation, at the heart of which is a 'no blame' ethos. This was originally modelled on the USN's organisation in the 1950s, which goes to show that good ideas don't have to be new ones. I had close contact with the RAF's flight safety system after formation of JFH, and it was a real shock to be jumped back 20 years or so to a culture of blame, concealment and reaction. Honestly, it was that bad. As ever, i'd point out that most of the people involved were honest, conscientious and professional. But the system that they had developed was basically flawed.

Second, ownership of the accident investigators. I've been told that we now have an absolutely unique system in that our Air Accident Investigators are 'owned' by an Airworthiness Authority. In my mind, this is a hopelessly flawed arrangement. Their activities and reports can now be controlled by the very people who are accountable for the regulation and delivery of airworthy aircraft. Conflict of interest, anyone?

Finally, practical airworthiness. Tuc has hit the nail clean on the head here. Doing airworthiness properly is not 'easy', but neither is it impossible. It can be organised and delivered to support front line operations in a safe and flexible way, giving the operators what they need (Note - not always what they want) and what is acceptable safe. Some bits of it are harder to understand than others, but given halfway decent training and a bit of experience, plus adequate regulation and guidance, it's perfectly 'doable'. In my own experience, the MAA is not yet helping people get there.

Best Regards

Engines

Good post Engines. Strange, isn't it, that an arbitrary and seemingly unjust decision in a Greek court triggers a recognition here of the arbitrary and unjust system that is UK Military Airworthiness Provision and Air Accident Investigation? Our situation is far more serious though, for not only have juniors been made scapegoats (even posthumously) but people have died. 62 of them in Airworthiness Related Fatal Air Accidents featured in this forum alone. That is the real scandal, that professionals are aware of the dysfunctional system that purports to be UK Military Flight Safety, they have reported it to Coroners, Fatal Accident Inquiries, Houses of Commons and Lords Committees, the Media, the RAF Provost Marshal, MPs and Ministers, and yet it remains compromised. Air Safety is not a plaything of politicians and Air Marshals to toy with but a highly technical system requiring continuous updating and evolution. 1987 was the date that an asteroid hit that system and was as devastating in its effect as any that affected life on earth in pre history. We are still reeling from it a quarter of a century later. No amount of sticking plasters, changing signs on doors or names of organisations will put it right. There has to be open recognition of the corruption and negligence that has brought us to this pass, and the necessity to remove Regulatory Enforcement and Accident Investigation from the operator, AKA the MOD. Haddon-Cave recognised the need for an MAA and MAAIB but failed to ensure their independence, the most vital thing of all. Until that happens avoidable UK military fatal air accidents will go on killing and wasting needlessly.

Chug



Coincidentally, I was asked to give some thought to a prime example of this the other day (in the context of MoD’s behaviour over aircraft crashes). Quite the worst and most blatant example I could think of occurred in the Mull of Kintyre case. One has to remember that the aircraft had no operational clearance whatsoever for ANY Nav or Comms. Unknown to them, because the information had been withheld, the pilots were not permitted to rely on these systems in any way whatsoever. This was confirmed by Lord Philip, who referred to these as ”mandated restrictions” (para 2.2.8). (He omitted the fine detail, so one has to read the Release to Service separately to find out precisely what was “mandated”. MoD denied it's very existence, until Lord Philip put this in his report!).


On 28th January 1997, upon broadcast of a Channel 4 TV programme, the retired and highly distinguished Marshal of the Royal Air Force Sir John Grandy wrote to the current Chief of the Air Staff, ACM Sir Michael Graydon seeking views.



In his reply dated 4th February 1997, Graydon offered a few gems;


1. The President of the Board of Inquiry “carried out a barely adequate job” because he avoided “attribution of negligence to the pilots”. Nothing illustrates better the fact the case was prejudged in the minds of senior officers.
2. That the analysis of the “Farnborough scientists” (i.e. the AAIB) showed aircrew error “must have been the primary factor”. This is a gross misrepresentation of the AAIB’s position and wholly refuted by their lead investigator, Mr Cable.

However, by far the worst was this;

3. He states the aircraft “was off course by some MILES” when it hit the ground. He confirms that he and Wratten briefed Sir Malcolm Rifkind, Secretary of State for Defence, of the above.



Never can a single statement have better illustrated the systemic corruption and concerted efforts to brief against the pilots.



One wonders what the original letter from Sir John said, but the intent of Graydon’s is perfectly clear. It served to foster an image of grossly negligent, and even incompetent, pilots being “miles” off course in such a short time, and clearly designed to rebut any notion they were not negligent. One assumes it would have been highly inconvenient had the distinguished Sir John Grandy written to the press questioning the verdict. Worse, Rifkind would have considered such a "fact" pretty damning and he has since confirmed he'd have taken a different view had he known the truth.


This evidence was presented by the Mull Group who, perhaps due to legal advice, opined CAS had been misinformed or misunderstood. That is too polite – I think it was an outright lie which served to suborn the entire process, and entirely typical of MoD’s behaviour at the time and since.



Corruption? Yes. These actions were a gross perversion of the integrity required of any officer, but set the tone for entire generations. You only have to consider how long the MoD maintained these lies, despite knowing the truth. People have lost knighthoods for less. And anyone involved is tainted and has no place in the current regulatory system.

Scapegoat Indeed
 

well said Tuc, rarely do i find myself disagreeing with your view(s).

Having just spent a great deal of my time reading safety guidance/policy I am at a loss how the simple error of not resetting a switch can result in an isolated prosecution. Taking the article with a pinch of salt (as it provides insufficient detail) I am at a loss as to how the manufacturer is not to be held at all culpable for designing a system which effectively has a single point of failure and no adequate redundancy or additional safety checks. I am not questioning the reasonableness of the prosecution, more the choice of defendants in this particular argument.

IMO there are underlying similarities with Nimrod in this instance as it is questionable whether a sufficient FMECA and hazard identification has been carried out on the system and it has been operated with apparent scant regard for such a failure mechanism.

Let's hope the legal decision is not followed elsewhere in Europe.

H

Obviously I'm not familiar with the 737 checklists, but I have to wonder why the pilots don't have some responsibility for getting airborne with a cockpit switch in the wrong position - a claim that is clearly in some doubt anyway.

If that was cause (and not the suspicion that there was a leaking door seal - the reason for the pressurization check being carried out) then the crew should have had at least two opportunities to set the pressurization switch to the correct position before take-off.

Even missing that, they would surely have had a cabin altitude warning as they were climbing to altitude. Would lack of pressurization not have caused equipment cooling issues too? I would think that would also trigger cockpit warnings.

So, my question is, what the hell were the crew doing? To me this is like a pilot running out fuel and then blaming the groundcrew for not putting more AVTUR in the jet.

My thoughts here in no way detract from the utter pig's ear the judiciary have made of this. I just think the blame is directed in completely the wrong direction.

There's an interesting point here and I'd be grateful for any comment from more experienced safety practitioners.

The sort of incident being discussed here is one where a switch was not correctly selected, or left incorrectly set. The point is - how does one assess the probability of someone making an error like that? You can mitigate the effects by system indications and attention getters, but at some stage you get to the stage where if a pilot pulls a lever or makes a switch when it's not safe to do so, you probably have an incipient accident under way.

Even if you could mitigate it, you'd need to state a probability of error at the start of any fault tree analysis.

So, does anyone know of any approved criteria for assessing probability of operator error?

Best Regards as ever,

Engines

Courtney, I doubt anyone who has posted here, including the OP, would disagree with you one iota. But it would be more appropriate if such analysis took place on another forum. This is a military forum and it is the military connections, and in particular UK ones, that are under discussion. I suggest that was clearly the purpose of the OP, and of everyone else who has posted. You suggest that the engineer is a scapegoat, for the pilots, the airline, the airworthiness authority, or whoever. You are almost certainly correct.
So what about the allegations made here about juniors, be they pilots or SOs being made the scapegoats of senior Air Rank officers? What about the allegations of outright lies told by senior Air Officers? What about allegations of corruption and gross negligence by senior Air Officers? What of allegations that the UK Military Airworthiness Regulations were wilfully suborned by, and on the direct orders of, senior Air Officers. These are the points that require urgent analysis by anyone who cares not only professionally but emotionally about the honour and integrity of the Military High Command. In particular it should be the concern of anyone, serving or retired, that the UK military airfleets be restored to airworthiness and be subject to professional air accident investigation. Are we as one about all these issues?

Not that I want to take anything away from these really excellent and revealing posts; but we should understand that "the law" in many countries is not really about justice and in many cases not about truth either. In some cases it is more about who pays a penalty for what went wrong, whether that is time in clink or money in pockets.

I know that this judgement is not in line with international air law but I don't know enough about Greek law to say what the point of this judgement is. I suspect it is up for some form of negotiation.


Yes Chug, I'm with your campaign.

Of course. But I still cannot look at a case like this without considering who is really to blame for an accident. Sorry if you feel this other side of the incident should not be considered here.

Courtney,
I am a 737 Engineer (Albeit -3/4/500's some 7 or 8 years ago) and the manuals did have a one-liner in the depths of some 1,000 pages about returning switches to their normal positions. But I never knew it until after this incident.

Of the four people charged and later convicted and sentenced in-absentia for this accident; none of them could be "blamed" for the recorded cockpit confusion, misinterpretation and prolonged inaction of the crew during this tragic flight.

However, the real question on this thread is: If the MAA were in the same position who would get the Chop? And why?

Without real independence and a directive to find the actual root cause, the end result of any accident or incident investigation is not likely to be clear or beneficial to anyone.

The negative thing to come out of this is the effect on flight safety, normally one would help with any incident (if one was ever involved in one) which aids the investigation and hopefully prevents the likes of it happening again, confidential reporting etc has always worked for the benefit of all involved in the industry, hopefully preventing accidents happening in the future, but hang a 10 year sentence over someone like this and one could imagine the effect would simply be to shut that avenue of learning and prevention management down to the detriment of safety

Engines



Sorry, it’s a bit late and my brain hurts, but the basic answer is to look at the Safety Case Policy document for any given aircraft. In practice, the likes of Westland have a single document covering all their aircraft. It is excellent, and I hope they don’t mind me quoting it.

Judgements can only be made through a detailed consideration of the aircraft’s design features, and the consequences of design weaknesses, production deficiencies (including Quality Control) in the context of the operating scenario. Thus, a Safety Case MUST be produced by the Design Authority which;

1. Identifies the potential hazards which could arise
2. Categorises the effects of those hazards
3. Quantifies the probability of encountering those hazards
4. On the basis of a, b and c justifies acceptance of those hazards, or identifies the design changes needed to render them acceptable, and ,
5. Provides a permanent record of the above, which must be updated whenever modifications are introduced.

It then tells you how to do it...... which I won’t bother repeating here. Suffice to say, it is bread and butter to some very clever people at Westland who, I might add, have never once let me down. On the other hand, MoD let them down in spades...........

The PRACTICAL problem here is that the Safety Case MUST be based on a stated Build Standard; it follows that Build Standard must be maintained for the Safety Case to remain valid. The aircraft DA is but one of hundreds of DAs who contribute their own Safety Case for their products, be it a radio, a tyre or an engine. The Aircraft DA collates this into a Whole Aircraft Safety Case. It follows adequate contracting and control must exist over everything that contributes to the WASC – an MoD liability.

This is where MoD falls down, and where Industry have been provided with a big OUT. The last time it was practice to implement all of the above was 1991. It has always been policy, but if you remove funding (as AMSO/Chief Engineer did from 1991-on) then that policy becomes a mere aspiration. If you later resurrect funding, by definition you need to regress and plug the gaps in the audit trail created by the failure to do the work. (But to seek funding for this is to criticise senior staffs, so few bother and hope nothing goes wrong).


Two practical obstacles. First, the increasing tendency to ignore the regs covering Service Mods meant few Safety Cases were updated (see 5. above). The chances of finding a valid Safety Case for an In Service aircraft are zero! Second, the work I describe was always carried out by specialists who were specifically trained in this field, and to whom it was their entire job. No one I ever worked with had less than 15 years relevant experience before being granted this delegation and position of a Technical Agency (the named individual responsible for maintaining the Build Standard and who, in practice, maintains the Safety Case). When the Chief Engineer disbanded this entire structure, culminating in scrapping HQ Mods Committees in June 1993, these specialists were redeployed and scattered to the four winds, never to be replaced. They would later bring their experience to bear as best they could, and you will find those aircraft/equipments they worked on have the most valid Safety Cases. Today, instead of this being a Central function to a few specialists, it is a minor task to hundreds; very few of whom actually understand what they are trying to achieve.

The main reasons for it being a Central task, is that maintaining the Build Standard is not, in the main, volume related. You need a Safety Case whether you have one, or one hundred, aircraft. But the Chief Engineer’s decision (sorry, keep coming back to this joker, but he’s a key player) to remove it as a Central function and lump it in with support (spares, repair) meant that when there was (say) a 25% reduction in numbers, this activity also took a 25% hit, despite it not being able to withstand any hit if safety was to be maintained. I hope this makes sense.

As applied to this case, if the reporting is true, somebody’s made a poor job of managing the Safety Case and the hazard, if it was identified in the first place. But that is just a guess based on little evidence at the moment. At least the pilot is alive to fight his own case, something denied many who have been killed by MoD’s actions I describe above.

Courtney:
Indeed you are right, for every accident should bear such scrutiny. The point that I was laboriously trying to make is that in the case of UK military aviation they do not, because of the negligence and corruption of the MOD which is poacher/gamekeeper/judge/jury over its own actions and inactions.
Corruption is a very emotive and pejorative word, but what one better describes a system that suborns its own mandatory safety regulations, persecutes those who will not thus conform, subverts the findings of its own inquiries into the resultant accidents and then lies and obstructs attempts to discover, in your words, "who is really to blame for an accident"? Those who served such a system in doing all this are themselves corrupt, but there are many within and without the MOD who have resisted and fought against this corruption. They are to be celebrated alongside the bravest of the brave, the bereaved loved ones of the victims of this scandal. Their courage to demand the truth in order that others should not bear the needless never ending pain that they have to is humbling.

Rigga, thank you for your declared support, but it is not "my" fight for I am but a mere standard bearer, it is the fight of everyone who cares about Air Safety, be they civilian, Service, serving, or retired. Anyone who considers themselves to be an aviation professional and does not see this as a fight which they personally should join has no right to that title in my view. When non professionals such as the NoK mentioned above have to direct professionals into realising that there is "something wrong with their bloody aircraft", you wonder at the meaning of the word. It took an HM Coroner (serving in an 800 year old institution) to tell the Royal Air Force that very thing before it would acknowledge it. There are many "professionals" who should hang their heads in shame in the way they have chosen to turn a blind eye to this corruption.
" All that is necessary for the triumph of evil is that good men do nothing."
-Edmund Burke?

Can I just clear up one thing?......'blame'.

This is a word that gets my hackles up a little.

True aviation professionals should rarely allocate 'blame' - if ever.

No pilot, crew-member, ATC contoller or engineer ever goes to work wanting to risk lives or kill themselves (unless they are intent on sabotage). However, people are human and they make mistakes - but often those 'mistakes' actually make sense, in heat of the moment', to those that perpetrate them - this makes genuine error near enough 'blameless'.

Saying the cause of the accident was a lack of situational awareness, poor adherence to SOPs or processes etc, is no better than saying 'operator negligence' and places the 'blame' directly on the the last actor in the scene - this is something we should be getting right by now but many accident reports (and courts) just don't get it right....still - and this, after many years of Jim Reason and Sidney Dekker et al pointing the way to a better (and more cost-effective) safety culture.

What's more, in some countries like France and Greece, this flawed 'cause analysis' allows the legal vultures to have an 'in' on criminal negligence and litigation.
(This is apparent with the Helios engineer, who is the victim of a complicated political and moral morass that is often found in most legal systems.)

But if the 'final' fatal mistakes have any migitating circumstances - reduced training hours, culmulative fatigue/stress, group-think, deviant norms, finnancial/operational pressures or the like - then the accident rapidly becomes the result of a vulnerable organisational environment, reducing the 'blame' on the final actor(s). Most genuine errors have such mitigations.

In my opinion, the only time that 'blame' can be placed almost fully on an individual is when someone is told that a certain course of action increases the risks of an accident to unacceptable proportions - using common-sense and not just the statistics of probability/ALARP theory. This doesn't stop them making a 'command-decision' but if that person then carries on with their course of action without reducing/minimising the risks, then he/she is ultimately responsible for that decision and should be aware that 'blame' may fall on his/her head if things go pear-shaped. Such is the theoretical responsibility of command and why one 'in command' gets the extra money and fringe-benefits! This is also why responsibility should travel up the chain of command - while orders and sh!t flow the other way!

But, quite often, the person making the decision is senior and, as often as not, the means to reduce risks cost money and eat up their budgets and minimise their promotion prospects - so they often don't do what is right and people die. These senior people are the ones who should shoulder the majority of any 'blame'.

Of course, that is what should happen but it is difficult to pin this responsibility onto senior people; they employ expensive lawyers (as in a number of various preventable railway accidents) or, in the case of the military, are part of an apparently 'untouchable' cadre of senior-officers whom no-one has the cohones to 'out' - those within the cadre cannot speak out (or so they believe) because they depend on the collective protection of the cliquey 'star chamber' to guarantee their work and pensions; group-think and deviant norms in action!
T'was ever thus, I suppose but it doesn't make it right.

The only other time that blame can be allocated is when (to coin a phrase) 'there is absolutely no doubt whatsoever'. e.g. a plane crashes inverted, whilst trying to fly under a bridge or doing a fly-by and the CVR captures the pilots agreeing to do it for a lark!

In the Helios case however, the pilots, though obviously not as able as some, have a degree of mitigation (that creates some doubt) in that they had other equipment distractions that may have prevented them spotting their own error (not setting up the pressurisation panel correctly, nor spotting it during taxy and take-off), along with some possible trg and supervision deficiencies. Perhaps this is why they didn't do the obvious thing (to us, in the comfort of our own homes) and level off at FL100 - but we will never know exactly why, sadly. Ultimately, they paid the highest price for their errors - and this, if nothing else, serves as a stark warning to all others who fly still. Total 'blame'? I'm not so sure.

Also, the warning horn was not of the best design (this doesn't then 'blame' the manufacturer immediately but it is something that should have been designed out as no-one, apparently, spotted this latent error - certainly, I wasn't aware of it when flew the B737 - I don't remember it being taught on the CBT either. OTOH, it might be a different matter if this circumstance had been specifically warned of (to Boeing), prior to this accident.....).

It is, however, plainly mad to almost-solely 'blame' the engineer for his one minor error before the crew made theirs - and even his 'error' is debateable iaw manuals etc. Godness knows how many mitigations he has for this and any lawyer worth his salt should be able to argue his case - expensive. Or just that he never goes to Greece again - the latter is the cheaper option and ultimately more agreeable to one's constitution - Greece is a depressing place at the moment!

"Blame? Only in extremis". I say.

(Mind you, there are few well-known senior RAF officers, as yet to accept their blameful moral responsibility, who should go their graves burdened by this guilt. I am of the opinion that it will catch up with them one day.
It is, however, never too late to repent - it would do the world of aviation safety great good for them to publicly accept they got it wrong - a true legacy - not just a row of tin medals on a shabby, faded uniform - left to gather dust in an attic or museum.)

I always find it interesting that blame is always considered as a one dimensional thing that is usually applied to the individual actors in an occurrence. As many have already stated, often it is the organisation behind those actors that has contributed to the decisions that are made by well meaning individuals trying to do their best with what they have. The thing is that the right culture is hard won and easily lost. The challenge for any regulator is having the balls to intervene appropriately to uphold 'Just Culture', but first having ensured a properly subjective investigation has been carried out to support any decision on culpability.

The fact that the UK Military operates within a single legal system whilst being, in effect, the airline, the ATM provider and the Airport operator as well as the investigator and the regulator should make the task far easier. Especially compared to the civil aviation industry in Europe with such a diversity of legal frameworks and so many different organisations and national institutions between the flight crew/ engineers and the regulators.

Quite agree - but its that word 'should' again......
:hmm::hmm:

tff:
Disagree, I'm afraid. It is that very unholy trinity of operator, investigator, and regulator that is at the very core of the problem. Would you fly with a civilian airline that investigated and regulated itself? Unless of course you subscribe to Liam Fox's endorsement of "honourable men"....

The fact that the UK Military operates within a single legal system whilst being, in effect, the airline, the ATM provider and the Airport operator as well as the investigator and the regulator should make the task far easier.

The single authority system you quote encourages a closed shop attitude and a "Need to know" culture that drives busloads of reasons out to end-users/operators not to engage in a Just Culture aspiration. It will never realise a safety culture purely because of the lack of independence (and therefore a lack of confidentiality) in any area of any authority.

In fact reading several accident reports since the Nimrod incident it is increasingly apparent that many RAF personnel are quickly learning to "take the 5th" when it comes to accident investigations - and who can "blame" them in the currently vague policy situation?

Chug,
I won't support your campaign then...I'll just jump up on the Bandwagon.

If that's the bandwagon that's heading for a totally independent MAA and likewise MAAIB, then squeeze over please and make room for me! ;-)

Quite right. I was listening again to a Coroner's Inquest the other day and the MoD witnesses were like Richard Nixon - I don't recall, I don't recall.

If they even sounded like giving a straight answer, there was a fit of violent coughing from the MoD benches and they'd stop in their tracks. What the families objected to was the fact this was obviously agreed in advance with the Coroner (and the families' barristers), who didn't once complain in the 4 days.

Eventually, one RN officer couldn't help himself. He'd been asked a simple, benign question by the Coroner and he answered. He ignored the ever louder coughing, until eventually there was a shout from the MoD benches "You're not meant to answer questions". And a louder one from the father of a deceased pilot "What a ***** fix".

Like something out of Yes, Minister, if it were not so tragic.

Unfortunately when fatalities & or serious injuries occurr you move without the RAF Just culture & into the civil law,which is neither just or fair.

Although there is a reactive element,the main thrust of trying to foster a just culture, is to move from reactive,through proactive & onwards to predictive.
People need to report, to highlight those pre-cursor events which lead to platform loss & fatalities. Having worked with the FAA they are a long way behind the curve,there is a huge element of complacency regarding Just Culture,reporting & investigation. See the Semmelwiess reflex. There is a huge disconnect between command & the coal face,they don't have a scooby about the unwarranted risks their people are taking.

Confused here by two diametrically opposed positions re the cultural differences between RAF and FAA. Engines and Pheasant are positive about FAA and Just Culture, woptb has a very different view. Surely given the AAIB and MAA sit over both organisations as regulator and investigator the outcome would be the same regardless of the colour of uniform?
Please don't make this 'my service is better than yours'
I wonder whether the posters above worked a mix of RW, FW, ships flight or embarked sqn?

Just Culture, Reporting and Investigation

From a personal perspective, I think the problem is consistent implementation and lack of independence, or at least independent oversight.


A “Just Culture” has been enshrined in MoD rules for some years. Individuals are responsible for their own actions, but if they are knowingly placed in a position by their superiors/management whereby their reasonable actions can cause an accident, then is it “just” to blame that individual?



Only the managers/superiors have the authority to correct attitude, resource and organisational failures which commonly cause accidents. Was it “just” to blame the Chinook pilots when their superiors knew the aircraft was unairworthy and not fit for purpose, but withheld this vital information? Was it “just” to continue to describe those senior officers as “honourable men”? Was it “just” to whitewash over the serious organisational failures, when flat refusal to learn from these mistakes demonstrably exacerbated the failures and led to further fatal accidents?



A Just Culture is one in which individuals are not free of blame if they are culpably negligent and where the organisation gives due regard to honesty. And the organisation must be willing and able to learn from mistakes. MoD comes nowhere near meeting these criteria. At the XV179 C130 inquest, evidence was heard of MoD’s bullying reaction to an RAF officer who, years before, had recommended Explosive Suppressant Foam (which was mandated anyway, an inconvenient fact whitewashed over by MoD). He was proven right, but at the expense of his career. For 16 years MoD dismissed in the most patronising terms the key evidence of Odiham’s Test Pilot that the Chinook was susceptible to serious UFCMs that perfectly explained what was known about the last few seconds of the flight. It was only in late 2010 that they inadvertently released the evidence that proved Sqn Ldr Burke 100% correct, in the form of a Special Flying Instruction that had been issued, but not forwarded to Front Line. Is it “just” to have a rule that states staff may be disciplined for refusing an illegal order to sign that an aircraft is safe, when it is not? And so on.




Reporting & Investigation:



1. Fault Reporting & Investigation. See above, same senior officers (primarily under Alcock, Chief Engineer 1991-96) directed that Fault Reports should be saved up and only submitted in Omnibus form, regardless of the immediacy of flight safety risks; and then refused to release funding to conduct the investigations anyway. As there was (apparently) no work to do, the specialist posts were chopped and department disbanded. The legacy of this policy remains with us today, because MoD has very few people who have been trained to do this properly. In a “Just Culture” system, who is responsible for this mess, and the resultant deaths? MoD don’t even understand the question, never mind know the answer.


2. Accident Investigation. The likes of the AAIB are superb. But is it a “just culture” when their expert reports are either ignored or twisted by MoD to “situate the appreciation”. At the time of the Mull of Kintyre crash, the AAIB’s recommendations from the 1987 Falkland Islands crash were still not implemented. The 1992 CHART report, and various from Boscombe Down’s, had repeated many of them, but all were buried. Again, is it “just” those pilots were blamed when implementing any one of these reports would have prevented the accident? (In the sense implementation would have prevented release of the unairworthy aircraft).





In many quarters these same seniors are seen to have “lost” the Mull of Kintyre case, but actually they have come out on top, in the sense they have been declared “honourable men” in the face of overwhelming evidence of deceit and failure of Duty of Care. Not just failure, flat refusal. Demonstrably, it is not a “just” culture when the default position is to protect those who conducted a 16 year whitewash, on the basis of their rank and title.



This whitewashing of the facts not only protects the guilty, but prevents MoD learning from the mistakes. But, does MoD actually want to learn? If the head of the MAA had any balls, he’d announce he was conducting his own review, this time addressing the irrefutable evidence that neither Haddon-Cave nor Lord Philip published. (Has he been given this evidence? If not, the decision to withhold it seriously compromises his ability to do his job, and deliver aviation safety; and constitutes a serious offence. Conversely, has he sought it? If not, why not? Scared it’ll affect the next promotion? He knows it exists; failure to correct the organisational failures it reveals is also an offence). Time to stand up and be counted.


What is required to implement a “Just Culture” in this context? An independent MAA and MAAIB.

Bravo, tuc, a great post! You spell out clearly the dereliction of duty that has cost both lives and treasure over 25 years, and will continue to do so until this scandal is confronted and corrected.

It is not only the head of the MAA who has to stand up and be counted, but the entire UK Military Aviation community.

It isn't only the FAA that can be reasonably be charged with complacency, but the entire UK Military Aviation community.

Unless the evidence that has been amassed and presented of the Gross Negligence, Illegal Actions, and Malevolence that characterised the actions of the MOD and the Military High Command is acted upon it will be a verdict on the entire UK Military Aviation community.

Time to stand up and to display your professionalism if you claim that you are a part of the UK Military Aviation community!

Going by woptb and others posts, it seems that a form of Just Culture may indeed exist - but only at localised levels such as within unit controls and probably driven by individuals (and not necessarily processes) keeping to the rules they have been taught and doing their best to stay within the meaning of those rules.

But it also seems that the higher up the "safety" chain the larger issues travel the more corrupt the interpretation of evidence becomes which subsequently degrades the validity of any corrective and preventive actions.

Even within the so-called safety of service bounds this again is an unsustainable system where the actors at the shop floor are trying to drive the actors in the ivory towers (to do the right thing?)

It just can't work without a third independant party to act as an AUTHORITY to be heard by all the players if not actually heeded.


woptb,

"There is a huge disconnect between command & the coal face,they don't have a scooby about the unwarranted risks their people are taking. "

Are you sure they don't know? Or are the maintenance hierarchy counting on the success of bad practice done in good faith?

A small mind numbingly nerdy point tuc, but........

"That the analysis of the “Farnborough scientists” (i.e. the AAIB)"

Probably refers to the learned gentlemen from the then RAF Institute of Aviation Medicine (IAM) not the AAIB. The IAM, which included aviation Human Factors specialists and Psychologists amongst its numbers, was based at Farnborough at the time. I think I'm correct in saying that the AAIB may also have called upon the services of the IAM from time to time, particularly in the case of RAF accidents. The IAM ended up ultimately as part of the QinetiQ empire and the closest MoD equivalent now is the boys and girls of the RAF Centre of Aviation Medicine (RAFCAM).

The good and the great of the AAIB are either operators or engineers and would probably take umbrage (particularly Tony Cable!) at being labelled 'scientists' :}

Apologies, back to my collection of rivet rubbings now.

There are a number of issues around 'Air Safety' and 'Just Culture' being pushed around here. Perhaps this view might help.

'Just Culture' is a relatively recent arrival on the 'Safety' scene, and not a bad one, in my view. You can't argue with its aims and objectives, nor its key features. However, at the end of the day, it is just a statement of values and cultures, which then have to be implemented by an organisation.

That's where this discussion might have got caught. I think that there are MANY organisations involved in generating 'safe aviation', and they all have to deliver a 'just culture' in the way that they need. One size will never fit all. However, many of them have to work together.

Starting at the top is always a good military way to look at it, and we now have (for better or worse) an active MAA laying down regulations and ensuring compliance. However, it's my view that the MAA's main focus should really be at the higher levels, such as DE&S and the higher areas of MoD, where Tuc so clearly shows the failings of previous years. This is really important when aircraft and weapons are being procured, developed and brought into service. Honestly though, I'm not sure that looking to 'just culture' to overcome years of secrecy and obfuscation is profitable. I agree with Tuc that you just need basic technical and managerial competence to be restored.

Once you leave those areas, you get to the operational commands, or for shorthand, RN, Army and RAF. 'Just Culture' really has to work here, often driven by the Services' own Flight Safety organisations, who are implementing not only MAA directives but also single service policies. I've worked with all three, and I know that the RN and the Fleet Air Arm have had an active and not at all complacent Flight Safety system for many years. I first heard 'Just Culture' mentioned in the RN around 11 or 12 years ago, and it's been heavily promoted since then, with strong leadership from the 2 star operational command, flowing down to stations, ships and squadrons. My own first hand experience of RAF 'Flight Safety' was not entirely positive, as (again my view), Strike were content to mainly leave 'Flight Safety' to their separate Inspectorate of Flight Safety (IFS), which had the effect of diluting the 'safety' and 'just culture' angle from the mainstream day to day activity of the Command. But, just my view from working there. Probably better now.

In the end, I suppose what I'm trying to get over is that 'just culture' has to be actually 'done' at all levels in a number of organisations - relying on MAA to 'deliver' it is not realistic. It also depends on good leadership, openness and honesty. If (like I had in 28 years in the RN) you have that, there's not much you can't achieve. I honestly believe that the RAF's 'pilot centric' culture, while fully understandable, is not always the best way to deliver the leadership and competency sets 'just culture' needs. It demeans the role of the engineer (and any other non-pilot role) and can sometimes promote officers who have little or no understanding of 'just culture'.

Finally, the issue of 'blame'. Just culture is clear, there is no room for playing a 'blame game'. What there has to be is clear accountability, backed up by sufficiently independent investigations and analysis. Here's a bit of a problem, because while I understand the objections raised to MAAIB being part of MAA, it gets harder to see where a really effective MAAIB would sit within Government. My view, and mine alone, is that it has to be linked to the Defence Safety Board, but that it must be carried out by people with sufficient current experience and technical ability to be able to conduct really effective investigations in war zones if need be. That means Service and civilian personnel. The RN's FSAIC concept (AIU collocated with Flight Safety Centre but separate) was actually praised by Haddon-Cave and then dismantled by MAA. Go figure. Again my own personal view is that the location of MAAIB within MAA, and more importantly, the largely RAF construct adopted for Service Inquiries are not at all optimal and will have to change in the future. They link the MAAIB far too closely to the MAA and also tie the role of the investigators too closely to the conduct of the Inquiries.

Put simply, everyone in the system has to have complete trust in the investigators to be thorough and completely independent. They also have to have trust in the way that Service Inquiries are conducted and their findings discharged. I think we still have the first, just. I just don't think that we have the second.

Best regards as ever

Engines