The Nimrod Review - Official Documents

The Nimrod Review
(6) There is a bias towards Equipment risks.
19.10
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Airworthiness is seen as an Equipment problem. Management focus and financial resources are often
channelled specifically to mitigate equipment risks, even though the highest Risk to Life for an aircraft is
likely to be Operational, i.e. to stem from its flying operations or its operating environments. Indeed, none
of the current top eight aviation safety risks on the Defence Aviation Strategic Safety Risk Register (DASSRR)
are platform airworthiness risks. They are: (1) aircraft availability; (2) operational commitments – structure
and manning levels; (3) operational accommodation; (4) risk of aerial collision against commercial air traffic/
general air traffic; (5) ‘brownout’; 7 (6) mid-air collision on Operation Herrick; (7) helicopter wire strikes; and
(8) risk of aerial collision – rotary wing.
(7) Airworthiness is diluted as a discipline.
19.11
Airworthiness is treated as a sub-set of the ‘Safety’ disciplines covered by the DE&S Safety Management
System. DE&S’ approach to ‘safety’ governance mixes Airworthiness risks with those related to ‘business’
or ‘environmental’ concerns. This dilutes the management of the more focused discipline of Airworthiness,
which is necessarily technical and concerned only with reducing Risk to Life. Regulations for Safety and
Airworthiness management overlap and duplicate each other in many areas. They are each written by
different sponsors yet are managed by the same Safety Managers on the Integrated Project Teams (IPTs), and
operating Airworthiness risks are left to the AOAs to consider separately. Without a standard set of criteria
for risk assessment there are inconsistencies in the way equipment risks are assessed on different platforms
and which are taken in isolation. Differences also exist across the boundary between the equipment and
operating authorities, which together make it impossible to identify what the actual Risk to Life is for any
platform. In terms of behaviour, the authorities have tended simply to ‘log’, i.e. record risks rather than
proactively manage them. Risk assessments which are made are often done in isolation and lack relative
context. As the equipment and operating authorities each manage their own risks, it is also not possible to
identify what the composite top Risks to Life are for a platform. As the Airworthiness hazard and risk criteria
is not directed by a single Regulator, discrepancies in the assessment have emerged which means that a
‘Category A’ for one platform does not compare with a ‘Category A’ for another platform in terms of the net
Risk to Life. This means that relative assessments cannot be made between technical and operational risks,
or across platforms so that resources can be apportioned effectively to reduce the net Risk to Life, and to
ensure that risk is owned at the right level. Risk is now managed in DE&S under the subject of general ‘safety
and environmental’ management. All types of risks, including those that do, and do not, have a Risk to Life
component, occupy the same Risk Register. The management of Airworthiness is thereby diluted.
(8) Airworthiness risks are managed separately by the equipment and operational domains.
19.12
Both equipment and operational risks are part of the operation of military air platforms. Equipment and
operational risks often overlap. Pro-active management of both together is a fundamental element of the
Airworthiness regulatory framework. Equipment and operational risks are, however, managed separately by
the Equipment and Operational domains as ‘equipment’ or ‘operational’ risks, with hazards logged (rather
than managed) separately, each with their own mitigation. Currently most risks captured by Integrated
Project Teams (IPTs) are related to equipment risks; and AOAs have their own separate risk databases which
are related to operational risks.
(9) Risk is poorly assessed across the various Defence organisations.
19.13
‘Equipment’ and ‘Operational’ risks are considered in isolation and under different criteria for each platform.
It is not possible to identify the top ‘Risks to Life’ for any one platform, or to compare risks associated with
one platform with another so that resources can be marshalled and directed appropriately. There is no broad
assessment of Risk to Life and appropriate allocation of resources. There is no evidence that the MOD takes,
or is able to take, a measured, broad, pan-MOD view on risk across all platforms, operations and lines of
development to ensures that limited resources are used to best effect to reduce the net Risk to Life. Instead,
7 Dust clouds reducing helicopter pilots visibility on take-off and landing.