Should Regulators and Investigators always be Separate and Independent of Operators?
Thread Starter
Should Regulators and Investigators always be Separate and Independent of Operators?
In the UK the above arrangement is holy writ in Civil Aviation. In contrast however the MOD Self Regulates and Investigates itself, formerly via itself and its subsidiary Services, latterly via its subsidiary MAA and MAAIB. In PPRuNe Military Forum Airworthiness Related Fatal Military Air Accident threads 62 deaths alone are accounted for. The real total is probably much higher.
Should not the successful separation of Regulation and Investigation into the independent CAA and AAIB be emulated by their military cousins as a matter of extreme urgency?
Should not the successful separation of Regulation and Investigation into the independent CAA and AAIB be emulated by their military cousins as a matter of extreme urgency?
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And a double fatality F-111 crash in Oz. Took the efforts of the pilots Mother to unearth the travesty of what led up to the accident, which the RAAF was only too happy to put down to "Pilot Error", as that took the heat off the organisation. Surprise, surprise.
Jan McNess (Mother) wrote a book "The Thirteenth Night". Highly recommended as a testament of a Mothers love, and unbending toil to right the wrongs of a bureaucracy that was only too happy to stain a good mans character.
Australian Story - The Chosen One
Jan McNess (Mother) wrote a book "The Thirteenth Night". Highly recommended as a testament of a Mothers love, and unbending toil to right the wrongs of a bureaucracy that was only too happy to stain a good mans character.
Australian Story - The Chosen One
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Ah yes, the Chinook! Well, let's leave that one aside for a moment, as many people seem to be suffering from 'Mull fatigue' - not least the MoD! Suffice to say that there is plenty of substantiated written evidence to show that the Chinook's regulatory airworthiness process fell well short of competence and fitness-for-purpose. Ultimately, I believe, this led to the crew unknowingly flying an aircraft that was definitively not safe at the time (whether that had any influence of the crash we cannot say).
But Mull is only the tip of the iceberg - take Nimrod, Hercules, Tornado, Sea King accidents - they all point to a broken down system of engineering design and oversight as having some bearing on the crashes. The breakdown of this process had its roots in poor budgetary decisions taken in the 1980's/90's which, in turn, led to the decimation of the airworthiness regulatory system of engineering husbandry/oversight. Furthermore, until the Nimrod in 2006, no RAF Board of Inquiry/Service Investigation dared to go there - bravo Air Commodore Clive Loader - it was his direction that led to most of the truth coming out in the BoI, the Coroner's Inquest and eventually the Haddon-Cave Review. As Chug says, at least 62 deaths- the total is probably a lot more - are directly attributable to this failed system of regulator, investigator and operator being one and the same.
Now the military has a new 'independent' Military Aviation Authority (MAA) and the Military Air Accident Investigation Branch (MAAIB), supposedly directly reporting to the Permanent Under Secretary of State (PUS) - which is at least a step in the right direction. But the reality is that MAA/MAAIB are still part of the higher-level MoD and so, by definition, 'undue influence' can still be brought to bear on the MAA. I believe it makes much more sense for the MAA/MAAIB to be totally removed from the military clique and be subsumed as a sub-section of the CAA/AAIB. This way, the MAA/MAAIB would gain even more independence from the insidious tentacles of the MoD hierarchy.
But that's not the whole problem. The MoD has retained very little engineering/regulatory experience in any of the Integrated Project Teams which do many of the tasks of the old 'Procurement Executive'. This lack of experience occured because of the way that the RAF airworthiness engineers were 'marginalised' in the many organisational changes of the 1990s - when logisitcians and non-engineering civil-servants took over the decision-making reins and the airworthiness chain was side-lined. Sadly, many good engineers retired and took with them their considerable experience and expertise and the MoD did nothing to discourage this bleeding of experience - itself against the regulations. Added to which, in the 1990s, the process of maintaining airworthiness took a 28% budget cut - 3 years in a row! I don't know if or how the MAA will ever recover the knowledge or the funding required to turn back the clock to a time when we had effective oversight of military aircraft safety.
Another stumbling block is that many of the incompetents (and their acolytes) who drove these policies in the 1990s and early 2000s are still serving - some at higher-levels or in consultancy. It is these bad apples that have the caused the rot but until their cavalier attitude to safety is wiped from the collective mindset, the MAA faces an uphill task to truly make safety a higher, if not the highest, priority and not the MoD's usual rhetoric - to which 62 souls can attest as a fallacy.
What is this thread doing on a technical forum? I hear you ask. Yes, there are similar threads on the military fora but I think we might all benefit if we were to hear from those who are our civilian brethren and counterparts - how/why does the CAA/EASA regulate and oversee airworthiness better (if they do) and why/how their practices could be adopted by MAA (if they aren't already).
Ultimately, we share the same bits of sky when we fly and military aircraft fly over our houses and over those of friends and families. The apparent lack of military airworthiness oversight concerns us all. To fail to address the issues above will mean more accidents in the future and as our military is shrinking to minuscule numbers, we cannot afford to lose a single aircraft (or their even-more-valuable crews) just because of a systemic lack of good engineering design/oversight.
(Incidently, another RAAF investigation into the F1-11 crash at Palau Aur was subject such 'undue influence' from above. 'Aircrew Error' was cited again but without the evidence to back it up. There was a concerted effort by the families and eventually the RAAF fessed up and admitted their errors of assessment and poor oversight.)
But Mull is only the tip of the iceberg - take Nimrod, Hercules, Tornado, Sea King accidents - they all point to a broken down system of engineering design and oversight as having some bearing on the crashes. The breakdown of this process had its roots in poor budgetary decisions taken in the 1980's/90's which, in turn, led to the decimation of the airworthiness regulatory system of engineering husbandry/oversight. Furthermore, until the Nimrod in 2006, no RAF Board of Inquiry/Service Investigation dared to go there - bravo Air Commodore Clive Loader - it was his direction that led to most of the truth coming out in the BoI, the Coroner's Inquest and eventually the Haddon-Cave Review. As Chug says, at least 62 deaths- the total is probably a lot more - are directly attributable to this failed system of regulator, investigator and operator being one and the same.
Now the military has a new 'independent' Military Aviation Authority (MAA) and the Military Air Accident Investigation Branch (MAAIB), supposedly directly reporting to the Permanent Under Secretary of State (PUS) - which is at least a step in the right direction. But the reality is that MAA/MAAIB are still part of the higher-level MoD and so, by definition, 'undue influence' can still be brought to bear on the MAA. I believe it makes much more sense for the MAA/MAAIB to be totally removed from the military clique and be subsumed as a sub-section of the CAA/AAIB. This way, the MAA/MAAIB would gain even more independence from the insidious tentacles of the MoD hierarchy.
But that's not the whole problem. The MoD has retained very little engineering/regulatory experience in any of the Integrated Project Teams which do many of the tasks of the old 'Procurement Executive'. This lack of experience occured because of the way that the RAF airworthiness engineers were 'marginalised' in the many organisational changes of the 1990s - when logisitcians and non-engineering civil-servants took over the decision-making reins and the airworthiness chain was side-lined. Sadly, many good engineers retired and took with them their considerable experience and expertise and the MoD did nothing to discourage this bleeding of experience - itself against the regulations. Added to which, in the 1990s, the process of maintaining airworthiness took a 28% budget cut - 3 years in a row! I don't know if or how the MAA will ever recover the knowledge or the funding required to turn back the clock to a time when we had effective oversight of military aircraft safety.
Another stumbling block is that many of the incompetents (and their acolytes) who drove these policies in the 1990s and early 2000s are still serving - some at higher-levels or in consultancy. It is these bad apples that have the caused the rot but until their cavalier attitude to safety is wiped from the collective mindset, the MAA faces an uphill task to truly make safety a higher, if not the highest, priority and not the MoD's usual rhetoric - to which 62 souls can attest as a fallacy.
What is this thread doing on a technical forum? I hear you ask. Yes, there are similar threads on the military fora but I think we might all benefit if we were to hear from those who are our civilian brethren and counterparts - how/why does the CAA/EASA regulate and oversee airworthiness better (if they do) and why/how their practices could be adopted by MAA (if they aren't already).
Ultimately, we share the same bits of sky when we fly and military aircraft fly over our houses and over those of friends and families. The apparent lack of military airworthiness oversight concerns us all. To fail to address the issues above will mean more accidents in the future and as our military is shrinking to minuscule numbers, we cannot afford to lose a single aircraft (or their even-more-valuable crews) just because of a systemic lack of good engineering design/oversight.
(Incidently, another RAAF investigation into the F1-11 crash at Palau Aur was subject such 'undue influence' from above. 'Aircrew Error' was cited again but without the evidence to back it up. There was a concerted effort by the families and eventually the RAAF fessed up and admitted their errors of assessment and poor oversight.)
Thread Starter
IGh:
Point taken IGh, and I for one do not take issue with you, for the NTSB is not alone in its sometime partial objectivity! But at least it is not employed directly by said big company. That is the issue with military aviation in the UK and, I suspect, elsewhere. Here the MOD is effectively both Regulator and Investigator. Thus if it makes a bodge of the first by, for instance, issuing a Controller Aircraft Release and a Release to Service to a knowingly grossly unairworthy aircraft type that shortly thereafter suffers an airworthiness related fatal air accident, it then ends up theoretically investigating its own shortcomings. In reality it doesn't of course, preferring instead to "discover" the alleged shortcomings of others.
No-one can claim that any system is fool proof, let alone scoundrel proof, but the self regulation and self investigation of military aviation is plainly partial, and no amount of Chinese walls or separate HQ's can alter that.
If only the problem of INVESTIGATOR-err could be solved so easily.
No-one can claim that any system is fool proof, let alone scoundrel proof, but the self regulation and self investigation of military aviation is plainly partial, and no amount of Chinese walls or separate HQ's can alter that.
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Palau Aur
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IIRC, there were also multiple failures of higher-level supervision and control of the exercise & sortie, that the F1-11G was not suitable for the mission, and that the sqn did not keep full currency records. The 'pilot error' bullsh!t was a convenient smokescreen, which the RAAF later withdrew and some Air Marshal was forced to retire early!
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Investigation is a science. Science has a method. It works, independent of the most biased politicians. What one does with it is constrained by the science. As above, a rose is a rose.
I'll cut to the chase. The foremost scientists are not in the employ of the Public. "National", "Federal", "Bureau", "Agency".
I'm trying to think of an endeavour in which investigations are scrupulously honest, and the results therefrom are Truthful in expression.
No luck so far.
I'll cut to the chase. The foremost scientists are not in the employ of the Public. "National", "Federal", "Bureau", "Agency".
I'm trying to think of an endeavour in which investigations are scrupulously honest, and the results therefrom are Truthful in expression.
No luck so far.
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I worked for an OEM's civilian product support group and was involved in several investigation. We shared a office complex with the military product support group.
One day on the way to work I heard that on of the military aircraft had crashed. I met the military groups manager as we walked into the complex and asked who would be going on the investigation. He said no one, we never participated in accident investigations, because the USAF handled them on their own?
One day on the way to work I heard that on of the military aircraft had crashed. I met the military groups manager as we walked into the complex and asked who would be going on the investigation. He said no one, we never participated in accident investigations, because the USAF handled them on their own?
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USAF I believe conducts 2 separate investigations - one, more military, to blame someone and the other, a safety investigation, to see what went wrong and what lessons can be learned. Perhaps someone could confirm and explain?
Of course, it is not too dissimilar in places like France/Italy/Spain (that don't have the UK's adversarial legal system). In these counties, the investigating Judge does the digging with the help of accident investigators but it is he who will decide if there is a criminal case to answer. I can't quite remember the ins and outs but I have a good article somewhere that explains why in some countries/organisations, blame gets lamped on someone - usually the poor sod in control - the last piece in the jigsaw - the one nearest the scene of carnage who often part of it.
Of course, it is not too dissimilar in places like France/Italy/Spain (that don't have the UK's adversarial legal system). In these counties, the investigating Judge does the digging with the help of accident investigators but it is he who will decide if there is a criminal case to answer. I can't quite remember the ins and outs but I have a good article somewhere that explains why in some countries/organisations, blame gets lamped on someone - usually the poor sod in control - the last piece in the jigsaw - the one nearest the scene of carnage who often part of it.
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IGh,
Forgive me, but I thought it was clearly established that the NTSB's role was to:
(Maybe later I'll put a few words together about the BEA...)
Forgive me, but I thought it was clearly established that the NTSB's role was to:
- make a big fuss about any investigation which isn't conducted according to their house rules, and then,
- leak all the details to the media as soon as it suits them...
(Maybe later I'll put a few words together about the BEA...)
Last edited by frontlefthamster; 11th Oct 2011 at 20:18.
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The need for Regulatory Authority independence
I have had sight of three RAF internal reports, namely the Chinook Airworthiness Review Team (CHART) report, the Nimrod Airworthiness Review Team (NART) report and the Hercules Airworthiness Review Team (HEART) report, all of which refer to the RAF’s Airworthiness Systemic failures dating back to at least 1980. During this time, some 62 airmen lost their lives unnecessarily because of Airworthiness related accidents. The reports are an extended litany of Airworthiness problems and failures that have remained unaddressed and which are still extant for unexplained reasons.
I refer to not only the Chinook HC2 ZD 576 that crashed on the MoK on 2 June 1994, but also the Falklands HC1 crash accident in 1987. Hercules XV179 crashed after a fuel tank exploded and Nimrod XV230 also crashed in flames and the aircraft was destroyed in the Iraq/Afghan Theatre of Operations, after an internal fuel leakage ignited in the air. Two Tornados and two Sea-Kings are also post-2000 accidents that must also be mentioned. The 'systemic airworthiness management failings’, as noted by Sir Charles Haddon-Cave QC, were also apparent in these later accidents after the rot had set in the mid 1980s, when certain RAF and MoD policies began to undermine the maintenance of through-life airworthiness. If Haddon-Cave had not limited his investigations to the 1998 baseline, he would have discovered the same failings in a number of fleets as mentioned by CHART, HEART and NART.
I find it unbelievable that those in the higher RAF echelons have consistently ignored the danger signals identified by their own senior investigating staff, thus allowing the systemic failures situation to fester-on, waiting for the next time a Service aircraft crashes due to the ongoing state of affairs.
That the MAA and MAAIB were created after the Haddon-Cave review is a step in the right direction. However, I speak as a retired Regulatory Authority inspector with 20 years of service in what was a truly independent UK Regulatory Authority, before EASA turned it into a Gateway to oversee the application of EC regulations. I proudly worked alongside those who previously regulated aviation Airworthiness independently as the Air Registration Board (ARB), later integrated into the CAA. They accepted no nonsense from Operators or Manufacturers in respect of the airworthiness standards they required to be maintained and did so without fear nor favour, whilst the Flight Operations department within the Safety Regulation Group, supervised UK airline operations in parallel. We were a truly independent Regulatory Authority in thought and in action, with set standards that were not negotiable.
I sincerely believe that like the CAA and the ARB, the present MAA headed by ACM Timo Anderson & its MAAIB offshoot, would have full freedom to operate a lot better if allowed to work without any MoD dependence whatsoever, so that they can act in the best interest of the Services; regardless of the current spin emanating from Whitehall that both are now truly free to perform independently. Really?
Ralph Kohn FRAeS
Retired airline captain and Regulatory Authority Fight Operations inspector & examiner of airmen
Compiler and co-author of the Chinook ‘Macdonald Year 2000’ report as later updated
I refer to not only the Chinook HC2 ZD 576 that crashed on the MoK on 2 June 1994, but also the Falklands HC1 crash accident in 1987. Hercules XV179 crashed after a fuel tank exploded and Nimrod XV230 also crashed in flames and the aircraft was destroyed in the Iraq/Afghan Theatre of Operations, after an internal fuel leakage ignited in the air. Two Tornados and two Sea-Kings are also post-2000 accidents that must also be mentioned. The 'systemic airworthiness management failings’, as noted by Sir Charles Haddon-Cave QC, were also apparent in these later accidents after the rot had set in the mid 1980s, when certain RAF and MoD policies began to undermine the maintenance of through-life airworthiness. If Haddon-Cave had not limited his investigations to the 1998 baseline, he would have discovered the same failings in a number of fleets as mentioned by CHART, HEART and NART.
I find it unbelievable that those in the higher RAF echelons have consistently ignored the danger signals identified by their own senior investigating staff, thus allowing the systemic failures situation to fester-on, waiting for the next time a Service aircraft crashes due to the ongoing state of affairs.
That the MAA and MAAIB were created after the Haddon-Cave review is a step in the right direction. However, I speak as a retired Regulatory Authority inspector with 20 years of service in what was a truly independent UK Regulatory Authority, before EASA turned it into a Gateway to oversee the application of EC regulations. I proudly worked alongside those who previously regulated aviation Airworthiness independently as the Air Registration Board (ARB), later integrated into the CAA. They accepted no nonsense from Operators or Manufacturers in respect of the airworthiness standards they required to be maintained and did so without fear nor favour, whilst the Flight Operations department within the Safety Regulation Group, supervised UK airline operations in parallel. We were a truly independent Regulatory Authority in thought and in action, with set standards that were not negotiable.
I sincerely believe that like the CAA and the ARB, the present MAA headed by ACM Timo Anderson & its MAAIB offshoot, would have full freedom to operate a lot better if allowed to work without any MoD dependence whatsoever, so that they can act in the best interest of the Services; regardless of the current spin emanating from Whitehall that both are now truly free to perform independently. Really?
Ralph Kohn FRAeS
Retired airline captain and Regulatory Authority Fight Operations inspector & examiner of airmen
Compiler and co-author of the Chinook ‘Macdonald Year 2000’ report as later updated
Thread Starter
flh, I don't think that an international Regulatory willy waving contest is going to get us very far. Let us all agree that our own Authority leaves many things to be desired and that they all have shortcomings and need to pull their socks up!
Having said that, I doubt if many of them have conspired to suborn their own regulations such that the very thing that they are there to prevent, ie unairworthy aircraft being allowed to fly, knowingly happens. Nor do I imagine that the subsequent air accidents are deliberately "managed" by the same Authority so that the truth of why these crashes happened is suppressed. The first may happen inadvertently, ie a seemingly airworthy aircraft turns out to be not so (the Comet 1 comes to mind). The second may happen in a mistaken effort to protect an important national employer (lots of examples here I'm sure but I don't intend to start off another tit-for-tat tirade!). The really dangerous scenario is where the Regulatory Authority has knowingly released unairworthy aircraft into service and then just as knowingly ensured that fact is suppressed in subsequent Accident Investigations. That recklessness is then compounded because in suborning its own Regulations for so long, that Authority has lost the ability to restore airworthiness to its fleets even if it wants to. That is the dire straight that UK Military Airworthiness now finds itself in. That is the difference between UK Military and Civil Aviation!
Having said that, I doubt if many of them have conspired to suborn their own regulations such that the very thing that they are there to prevent, ie unairworthy aircraft being allowed to fly, knowingly happens. Nor do I imagine that the subsequent air accidents are deliberately "managed" by the same Authority so that the truth of why these crashes happened is suppressed. The first may happen inadvertently, ie a seemingly airworthy aircraft turns out to be not so (the Comet 1 comes to mind). The second may happen in a mistaken effort to protect an important national employer (lots of examples here I'm sure but I don't intend to start off another tit-for-tat tirade!). The really dangerous scenario is where the Regulatory Authority has knowingly released unairworthy aircraft into service and then just as knowingly ensured that fact is suppressed in subsequent Accident Investigations. That recklessness is then compounded because in suborning its own Regulations for so long, that Authority has lost the ability to restore airworthiness to its fleets even if it wants to. That is the dire straight that UK Military Airworthiness now finds itself in. That is the difference between UK Military and Civil Aviation!
