EdSet100

Thank you for your acknowledgment. I think everyone here is like-minded on the real, underlying issue – its people who count and those at the top charged with implementing the regulations have abrogated their responsibilities to a criminal extent. I would not tar those of us at lower echelons with the same brush, however there are clearly those in PE/DPA/DLO over the years who have taken the ambivalence of senior staffs toward airworthiness as a benchmark, and just haven’t bothered. Especially when they saw what happened to people who disobeyed instructions to ignore airworthiness.



Nigel

To expand on the timeline.

BoI report prepared April 2007.

Ingram - June 2007 – Airworthiness regs are implemented properly.

Ainsworth – August 2007 - Ditto

Airs Staffs - November 2007 – Ditto

I’d say they were in complete denial over a very long period. I’d also say those who drafted Ministerial responses were incompetent and/or deliberately misled Ministers. Given MoD have been told all this repeatedly over a number of years, I’d say both. But, within a week a colossal penny dropped and Browne made his statement to the House. Someone, somewhere, clearly pointed out the significance of ACM Loader’s statement and it hit the fan.

EdSet100

"That was a report about hot air pipes inside the engine compartments;"

Wrong, I suggest you look at page 11 of the report and get YOUR facts right.

Tuc, in the case of the Herc fleet, I am sure that Ingram was deliberately lied to by a very senior RAF Officer. In fact there were several witnesses.

I read Ed Sets reasoning for the unprecedented actions after the Nimrod BoI was published. I am still of the opinion that political expedients were the main drivers. Browne needed to take the sting out of the situation, he apologized and announced a review. Something the Brown Govt has been doing almost continuously for months. Check out the following statement by Browne in response to intense and difficult questions by Gerald Howarth on the day the BoI was published.

"I did not recognise the circumstances that informed the hon. Gentleman’s first question, but that may be a failing on my part. As with several questions that he poses, I am sure that he accepts that it falls squarely in the remit of the review that I have announced today. Those questions are entitled to an answer. They cannot be answered by the BOI and should be answered by a process of independent investigation, and I have therefore set up the review. The questions will be passed on directly to the principal reviewer when he is appointed. Indeed, any other questions that Opposition Front Benchers identify as needing to be asked should be fed into the process in due course."

How very convenient. Ministers of the Crown have undoubtedly misled the British public. This review could still bite the Govt in the arrse.

Well EdSet100 you have had a great deal say. So let me comment on some of the things you have said.

Your understanding of the combustion report is WRONG. I suggest you read pages 3, 46 and 47, and then ask yourself why the recommendations are not mentioned in the BoI report.

Your understanding of the BAE duct report is WRONG. For the reason already pointed out by Tapper's Dad. If the BOI received the same information as you have posted, then it is no wonder they did not look at it. But they should have known after the XV227 incident

Your understanding of the 2006 QinetiQ report is WRONG. This was not an "interesting discussion about irrelevant fuel leaks", it was about mismanagement of information, outdated documentation, the inability to find faults back at base and undertake recommendations. These observations by QinetiQ were of the whole system.

Your understanding of what this forum achieved is WRONG. The Panorama programme was born out of this forum, and that programme discussed hot air pipes and couplings. Also, the 2006 QinetiQ report addresses remedial versus preventative maintenance, and recommends a change from the former to the latter.

Your understanding of why the Board re-conviened is WRONG. The board re-conviened for the six reasons stated in the report. And, one of the reasons starts with the phrase " in the light of new information.."

Your understanding of why myself and the families want a copy of the 2007 QinetiQ is WRONG. It is because, in the light of other evidence the statement made by Des Browne does not ring true. The families were told they would receive a copy on 5th Dec, and they are still waiting. If it is as straightforward as you make out, where is the problem? I would like to remind you that airworthiness is not just about the safety of the people who fly, but also the safety of the people who are being flown over. And right now we are asking the questions. Just answer these questions, if in Sept 2007 QinetiQ gave the impression that all was well, do you not question the validity of the report when a fuel line/coupling failed in Nov on XV235? If the report does not state the "Nimrod fuel system is safe", who attached that tag to it - IPT?

There is more that I could say, but I see little point. I am sure you will continue to defend the IPT/MOD/RAF line long after the QC has reported. I was told once by my old boss at Boscombe Down, that if a person gets one thing WRONG in a report/statement then you may as well toss the whole thing out of the window. Sorry but I have counted at least six


DV

Ed Set 100, just to let you know the majority of the families want all the documentation and are reading it cover to cover.

EdSet100 said:

Sorry Ed, it is simply wrong to blame the BAE Systems safety case, which included the following very clear caveat:

Anyone who tries to sue BAE Systems for something that happened over Afghanistan will therefore be wasting their money.

Nige, I work with that Captain and whilst his decision may not have been as rushed in different circumstances, he was certainly not pi$$ed off. I suggest you talk to him again and get the facts right from the horses mouth before posting on here.

That said, it would seem that info was available that should have been released to the front line sooner, not just wrt this incident, but for general handling of the aircraft. Until the BOI reported, we all thought 230 had had a bomb bay fire!!

VR, I never reveal my sources, as I did not speak to the skipper direct I have removed the reference from my post.

Regards,

Nige

Mick

You have picked up on a very significant point, one which I have raised several times on various threads on pprune. The MoD has a whole suite of Safety Cases which only cover peacetime operations. I spent several years both writing and reviewing MoD aviation related safety cases, and this is a major failing. The MoD has committed virtually all of its aircraft types, apart from training aircraft, to operations either in Afghanistan or Iraq, yet virtually all have peacetime safety cases. The guidance provided to IPTs is clear though. Safety Cases are to cover ALL operational scenarios, peacetime, training, and the catch all of Crisis, Tension and War. The guidance for this is clear to anyone who can read, and is provided in Defence Standard 00-56, JSP 553 and POSMS, three of the key safety management and airworthiness publications.

The simple fact of the matter is, that in many cases, the MoD simply does not have Safety Cases for the manner in which it operates many of its aircraft. And before anyone shouts me down on this, remember, a Safety Case must be based on the manner and the environment in which a system is used.

Of course, the Safety Case is not a legal requirement. However, it is the manner in which the MoD has chosen to demonstrate satisfaction of other legal obligations. It is an approach that is widely used in many industries and is well understood by those same industries. That is not the case generally in the MoD.

Responsibility for the aircraft Safety Case rests with the IPT Leader. Yes, the IPTL can bring in a third party to develop and maintain the Safety Case, but the responsibility for it rests with the him. It is written, in black and white, in JSP553.

I only have Change 3 of JSP553 to hand, but can’t imagine that this part has changed that much:
Does anyone on here know which independent organisation has reviewed the Nimrod Safety Case ?

S_H

S-H

Spot on, as usual.

The words used by BAeS, as quoted by MS, are fairly standard. They are NOT used as an industry “get out” but, in my experience, as a firm reminder that the MoD’s own actions are lacking. BAeS may be the Aircraft Design Authority, but the caveat is always that they, and the suppliers of what they call “vendor equipment” (avionics etc), must be under continual contract cover to maintain the Build Standard, which includes safety. If these contracts don’t exist, or are not properly funded or implemented, then the inevitable result is serial breaches of the airworthiness regs and an incomplete audit trail. A simple fact – they are not funded properly and in many cases contracts don’t exist. (This, in part, is what ACM Loader refers to in the BoI report). The MoD don’t deny this but, incredibly, state that RAF Wyton has the facility to do the necessary work. This is a blatant lie – if this were the case Wyton would be the biggest air station in the world and Huntingdon a city of half a million defence workers. Oh, and prior to 1993 it was RAF Swanton Morley who had this capability. Norwich must be a ghost town. Utter b@lls, but that is the nonsense they trot out as they dig ever deeper holes for themselves.

I know Boscombe have continually hit this problem over a long period. They fulfil their obligations and deliver MAR recommendations which may say “It’s physically safe, but when put to its intended use (warfighting) it is functionally unsafe”. Typically, this is written by a serving officer who understands the real need, and doesn’t for one minute contemplate a peacetime only scenario. Corrective action takes money and slips the programme. Pressure is brought to bear at a higher (administrative) level, and the peacetime rule S-H mentions is trotted out. The beancounter mentality prevails, the contracts are paid-off and the aircraft offered to the User for Release to Service. He’s caught between a rock and a hard place. Sign the RTS knowing the aircraft is not fit for purpose, or demand corrective action and incur the wrath of his bosses by delaying introduction. I know many suspect this, or something very close, is what happened on Chinook. And the Boscome officer? He returns to unit to fly that very aircraft and always at the back of his mind is the FACT that he KNOWS the aircraft is unfit for purpose. If he’s lucky, and there are some here who know exactly what I’m talking about, he can have a quiet word in a project manager’s ear; one who is prepared to ignore higher instruction and make the aircraft safe. But, this only fixes one aircraft type. What if the same problem exists in other aircraft? A different management chain is involved who object to being advised they have a problem, and do nothing. Unfortunately, as with the Tornado/Patriot accident, the result can be tragic.

This is precisely why the QC’s remit must include all aircraft, not just Nimrod. He must be allowed to assess the entire process, not just as it was applied to Nimrod in a given period.

tuc,

As you discuss, the exclusion isn't really an industry get out, but it can feel that way when you are trying to provide RTS recs! The key is to realise it is because industry don't know how it is really going to be used from the moment they hand the ac over. The words from Mick's post are actually quite sound, and somewhat better than a brief "this report covers the training mission defined in X" as I've seen.

An issue that I had to overcome was reminding the RTSA that their safety case had to cover operations, as required by JSP 553. It's amazing how many people that you would expect to know the contents of 553 don't really understand it.

sw

Hmmmm.......?

There are many systems aboard an aircraft which only have an operational or combat use, so I think to say that industry do not understand how the kit is used does not tell the full story.

It is certainly my experience that these words are used by both industry and MoD as a get out.

S_H

S_H,Agree completely, but what they are trying to get out of is quantifying the risk in a situation where the bad guys are biting back.

An outrageous example of this that I came across was a safety argument that (basically) said the risk of releasing the wrong weapon was eliminated because only one weapon would be carried on the aircraft at a time! This was based on the peacetime assertion that because weapons sorties are training missions carried out on ranges, only one weapon would need to be carried. :\

sw

Before I reply to some comments made in response to my last post, I would ask you to look at the time of day that I posted it. It was late and from home, where I don't have all the docs to hand. There was an element of memory testing in my message, and some of my refrences to documents were erroneous. So, where required, I have included apologies.

Nigegilb:
My understanding of the sequence of events and decisions is that the "suspend AAR" decision was taken immediately after the incident due to the nature and contents as written, of the incident report. I don't know the operational effect of that suspension, but I believe it was determined to be secondary to the suspension. Within days, an investigation was ordered and we still await its outcome. In the meantime we have been informed that the existing lack of operational capability by the Nimrod has been addressed. I recognise your quote and I still stand by it. Despite the criticism of leadership, the technical aspect, ie "it is as safe as it needs to be" still stands. I re-iterate that its in the present tense. I believe the report is at its final stage. I haven't read it, but the rumour is that CAS's words remain correct: the Nimrod is safe enough for AAR. But, there is a growing feeling that due to intrusive media and public pressure, the technical factor in the decision may be overruled for political reasons. However, growing media and public attention to the troops taking fire on the ground may encourage the politicians to provide those lads with the best surveillance support the RAF has to offer. Its being held back at the moment for no good technical reason.

TD:
My apology for wrongly saying that the report only contained data about engine compartments.

Underlying my reply to you are these two facts:

1. Part of the crossfeed pipe and the initial section of the SCP are in the bomb bay (as the diagram shows), but the BOI established that there was no fire, at all, within the bomb bay. Therefore, any possibility of duct failures within the bomb bay that might cause fires, while of some interest, was outside the BOI's terms of reference, because those ducts were in an area that didn't catch fire, therefore they could not have caused the fire. Analysis of duct failures within the bomb bay would have been nugatory and time wasting; particularly with bereaved families demanding answers.

2. The ducts that are in the area of the fire are surrounded by 5 leak detectors, set at 235C. There was no warning of a duct leak (the warning light is right next to the AAR control panel and would have been obvious and reported on intercom; it wasn't). So, any air leak that could have caused the fire would have been at a relatively low temperature and played straight onto an adjacent fuel pipe coupling (seal). This scenario was recognised as a possibility by the BOI. They did not need to check the BAe report; it was an obvious (though small) possibility from the outset and reported as such.

I re-iterate my answer that the BOI did not check that BAe report because it was either outside their Terms of Reference or it was not needed.

I find it intrigueing that you are critical of the BOI process and the officers who worked tirelessly to produce a document so damming that the SoS had no altermative but to stand up in the HoC and apologise to you and the other families, together with an unconditional offer of compensation.

DV:
I can only post once a day at the moment, so I have bunched up the comments together with my replies, and I do so again. You have said I am wrong on 7 points.

I have not read the combustion report. I am only re-iterating my understanding of the BOI's analysis of the report in the areas relevant to the accident. You have quoted specific pages, so please quote the relevant passages, in order for me to see where, in your view, I am wrong.

I don't know if the BOI received or read the BAe duct report but I hope my above answer to TD goes some way to explaining why it was not mentioned by the BOI.

I didn't mention the 2006 QQ report. I don't question its accuracy, but I do question its relevance to the accident. Anyway, I simply wrote what you have quoted above and within our pprune discussion there was nothing that was discussed or un-earthed here that the BOI team was not already aware of. I cannot believe that pprune led the BOI team to the QQ report.

Pprune, Panorama, Timesonline and RAF servicemen who should know better, might have caught the public's interest, but the fact of the matter is that no SoS will stand up in the HoC, say "sorry", and offer compensation, based on the "evidence" of the aforesaid media. He will be guided only by the officials within his dept, and in this case it was the compelling evidence provided by the RAF BOI, CinC and, I guess, the approval of the MOD legal eagles.

Yes, agreed. I don't why I wrote that throwaway comment from memory. It wasn't needed in the context I was writing at the time. However, I've checked out what the "...new information" was. Its in the BOI report on page 2 of Part 2A and the new info obviously came from the IPT or higher up the engineering chain (certainly not from any ppruner, panorama or timesonline because its defensive not aggresive). It clarifies how the RAF performed a mandatory review of failure trends to support its use of corrective maintenance.

And I still don't understand why the families are interested, now, in post accident matters. The MOD/RAF has done its best, through the BOI to explain, to the best of their abilities, what happened to XV230, together with any pre-accident factors that were relevant. Consequently, a formal and public apology with an unconditional offer of compensation has been given. Its not my place to say whether or not or this is satisfactory to the families, but I cannot understand how a report, post accident, examining revised procedures can change what the SoS has said and done. The report is restricted and it would appear that someone has decided, since the BOI day, that it cannot be put into the public domain. Thats my guess.

I'm not defending anyone. Like you, I prefer the truth. I have severely criticised the leaders for their slavish adherence to BOI protocol. I counted only 1 factual error in my previous message and I have acceded to your correction. If I don't understand something, that doesn't make me wrong. The other "wrong" points are a matter of opinion. You started this discussion many months ago and you have submitted many questions (recently I have given some thorough and correct technical answers) and messages. I will not check back in your contributions for errors. I'm sure there are one or two there, but I do not want to risk the need to toss all of your statements out of the window ;-) We all make mistakes.

Yet another late night......

Ed Sett

I have read your posts with interest. I don't agree with some of your views, but the infromation you have contributed has been very useful.

This I must comment on though:
Everyone connected with RAF/RN/Army aviation should take an interest in this, because the MoD has failed over many years to properly follow up recommendations of Boards of Inquiry. Notice I say follow up. I would not expect all recommendations to be implemented, it's not always practicable. But it is not unreasonable to expect to see them properly followed up.

It would be very interesting to look into BoI recommendations of say the last 30 years, and look at how many later accidents/incidents could be linked to not implementing the said recommendations.

S_H

Ed Set,

Thanks for taking the time. It is curious that AAR has not been re-instated. Maybe CAS has blown his credibility among the wider audience. Maybe it is not as safe as we have been led to believe. I struggle to understand what the difference is between this serious leak and the ones that have preceded it that didn't warrant this scrutiny. Ground testing has never been able to re-create the environmental conditions in-flight but the Nimrod was given a clean bill of health to continue every time til Nov. If we somehow contributed to that pressure here on this thread, then the Chiefs should ask themselves how they got themselves into a situation where an ageing airframe was chosen to have the very latest battlefield technology bolted on.
I heard the other day that one option on the table is to cancel Nimrod MRA4 even at this late stage. All rather extraordinary wouldn't you agree?

Time for a change?

Certainly hope the high ups review the handling of this case. I would recommend more honesty and more transparency straight away. A restricted document is not difficult to get round. I am not convinced lessons have been learnt here.

S-H

“It is certainly my experience that these words are used by both industry and MoD as a get out”.


If I could clarify what I said, because I don’t think you’re actually disagreeing with me.

It is important to establish contractual boundaries of responsibility. On a whole aircraft, there are typically 3 components – MoD, the Aircraft Design Authority and Equipment / Sub-System Design Authorities/Custodians.

The words quoted are simply the standard way of expressing that boundary from the ADA or DA/DC viewpoint. It is not abrogation of responsibility or trying to “get out”, it is an indication of a deeper understanding which is almost entirely lost on the MoD.
Most companies are happy to accept responsibility but they must be paid a fair and reasonable price, under a suitable contract which clearly states their responsibilities and articulates the control boundaries. It is the responsibility of the MoD (and seldom as low as IPT level as they don’t control everything in their aircraft) to ensure there are no gaps at these control boundaries. In practice, this is usually a 2 Star.

Admittedly, some companies flagrantly abrogate their responsibility, even when contracted properly, but the PE/DPA Nimrod 2 Star, CDP and successive Mins(AF) said that was ok, so I’m sure it is. Hopefully the QC will disagree. This is a simple thing to fix.

The procedures for exercising such seamless control over a design, and maintaining that design, are laid down in a Def Stan which the MoD have been trying to scrap for 13 years. It has not been updated for 17 years (Jan 91) and has largely fallen into disuse. A “waste of money” apparently. And because it is not applied properly - here we go again – there are gaping holes in airworthiness audit trails. This is the point made here many times and in various BoI reports involving fatalities – the procedures/processes/regulations are relatively robust (although some are outdated) but they are not implemented properly. This is a DELIBERATE MoD decision, therefore Companies MUST protect themselves in a legal sense.

In short, companies have a vested interest in their product being seen to be safe. MoD policy and practice militate against this.

I’m sorry for the detail, which I know many here understand, but I feel it important to make these distinctions. Things are coming to a head and fingers will be pointed. Some already point them at BAeS. I have read the various official reports which are available and, very clearly, BAeS and vendors have not been under contract to ensure a seamless audit trail. Also, and the QC’s remit is worded this way, the term “RAF” is used when it should be “MoD” and even “Government”. Having read, for example, the main QinetiQ report mentioned here, there are a few things the RAF could have done better, but the underlying problems are central. There is a danger of a cheap and nasty “fix” for Nimrod but the same thing happening again on other aircraft. Nimrod is not the first, it’s the one that has brought matters to a head.

Ed Sett; You say,
Have you really thought about what you have said there. You imply that prior to the BOI being set up, it was already established that there had been no fire in the bomb. So, the BOI was directed (by terms of reference) to ignore bomb bay items as a source and/or cause of the fire. Also, if you read my postings #2246 and 2247 you will be reminded of what the BOI said about hot air leaks in the bomb bay area. They make reference to the BAE duct study, but appear to be under the impression that no report was available. Whoever, gave them this impression mislead them.

DV

Mileandahalf

I agree the thread should stick to verifiable facts, and not speculate or sling mud.

The stage we are at now is pre-inquest and pre-QC review.

Some indisputable facts are;

• ACM Loader stated (reiterated) that airworthiness regs are not applied properly. This prompted SoS to admit liability and order the review.

• In doing so, SoS disagreed with his junior Ministers who, after the accident, are on record as stating the regs ARE implemented properly.

• The relevant MoD(PE) / DPA 2 Star ruled, in writing, that implementing these regs is optional, and seeking to implement a specific part of them is a disciplinary offence.

• CDP upheld this ruling, in writing. As did above Junior Ministers.

All the above documents are either personal letters, obtained under FoI or published on the MoD website. Nowhere do I mention RAF or BAeS. I’ll let the QC sort that lot out. MoD won’t.

Speak for yourself, mileandahalf, as I for one feel as tuc infers, that the state of airworthiness provision for UK military aircraft is at last being brought to a head in the aftermath of this tragic accident. I find it instructive that a common denominator in so many failures in this respect would appear to be the actions not of politicians, nor even of senior civil servants but of senior serving officers (2* and above). My conviction that the regulation of UK military airworthiness should be taken out of such hands and transferred to a separate, stand alone and independent Military Airworthiness Authority grows ever stronger. Peoples lives are of infinitely greater import than the reputations and career prospects of senior officers, however differently they may see it.