The Nimrod Review - Official Documents

Chapter 19 – Shortcomings of Current System
the MOD tends to focus and spend its money in making individual pieces of equipment (e.g. aero-engines)
extremely safe, which means that it does not have the resources to spend on other measures which might
significantly reduce the overall net Risk to Life (e.g. collision avoidance systems such as TCAS 8 or additional
spares). This imbalance is caused by myopia and a poor appreciation of the total risk picture. The result is
that resources are not targeted as effectively as they might be. Further, the difficulty in comparing like-withlike
and making relative assessments of risk across domains and platforms, means that the higher level
governance boards which manage Airworthiness across Defence (e.g. MARSB) lack appropriate information
to manage aviation risks or direct resources appropriately. The US Air Force Safety Center told me of a striking
example of the advantages of being able to address Risk to Life across all platforms and operations: the US
Navy, which assesses Risk to Life across all lines of development, came to realise that most aircrew deaths
and injuries at various aircraft bases were attributable to motorbike accidents and, as a result, it instigated
a successful advanced motorbike training programme, which substantially reduced road accident deaths for
aircrew, thereby preserving one of its most precious assets.
(10) There are too many different Hazard Risk Matrices.
19.14
There are a myriad of different Hazard Risk Matrices used to determine risk categorisations. This is confusing,
potentially dangerous, and makes it more difficult to compare risks across platforms.
(11) There is a lack of independence and transparency.
19.15
The Assistant Service Chiefs have each had bestowed on them the conflicting roles of Duty Holder and Release
to Service Authority. This runs entirely counter to the principle of independent regulation and assessment
which is a key tenet of proper Airworthiness regulation as practiced by e.g. the UK Civil Aviation Authority.
These are pivotal regulatory functions that the Assistant Chiefs are expected to undertake in addition to their
(very demanding) primary duties.
(12) There is a lack of consistency across all three Services.
19.16
Each of the three Services executes the Release to Service Authority function differently. The Navy and Army
carry out this regulatory function from within their operating authorities. The RAF relies on the expertise of
experienced air operators; the Navy relies on aircraft engineers; and the Army relies on a mixture. In effect,
there are three quite different arrangements for what is the same regulatory function, whilst none, in my
view, provides an example of best practice.
(13) The interface between the MOD and Industry is not working as it should.
19.17
The Regulator has initiated a move towards a more ‘civil’ Airworthiness regulatory model in order to seek to
improve the interface between Industry (who manufacture and support the MOD’s aircraft) and the Front Line
military. The transition to a ‘hybrid’ model has, however, proved difficult. This is due in part to the fundamental
differences between civil and military operations and to the difficulties of meshing different regulatory
systems. The Military Approved Organisation Scheme (MAOS) was devised to align with the approval system
used by the civil sector and to make it easier and less expensive for the MOD to contract with Industry. Those
Industry support organisations that have been approved under the MAOS system have been permitted to
devise their own systems for maintenance management. Unfortunately, these do not necessarily correlate
with those used by the Forward environment who operate and support the aircraft, which has e.g. made the
tracking of life critical components difficult. Most importantly, Industry MAOS support organisations will not
recognise engineering decisions made by the Front Line engineering officers taken e.g. to defer corrective
maintenance or accept capability limitations, even though these decisions are a fundamental requirement
for military air operations. Rather, Industry MAOS support organisations typically demand corrective action
before aircraft are handed over to Industry for routine maintenance. At RAF Marham, for instance, where
MAOS is in place, Industry has on occasion even been unwilling to recognise component life data issued
8 Traffic Collision Avoidance System.
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