The Nimrod Review - Official Documents

The Nimrod Review
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trails’ rather than check what is actually taking place on the ground. 11 Unlike in the Civil Sector, there is no
requirement for the AOAs to undertake annual Airworthiness reviews to confirm the Airworthiness of their
aircraft (although the Army have their own annual review process). The absence of any general formal annual
review process is one of the reasons why husbandry problems in relation to legacy aircraft have been allowed
to develop. Recent investigations have identified failings in the way aircraft husbandry of legacy aircraft has
been managed and carried out. 12 These shortcomings highlight the absence of any formal annual review
process to confirm the Airworthiness of individual aircraft where scheduled maintenance has not identified
the problem. There is, therefore, a need to review and align the re-certification processes used by each of the
Services, and to consider the benefits of adopting a military version of the Civil Type Certificate, Certificate
of Airworthiness, and the ARC. 13
(22) There is a lack of clarity in the type certification
19.26
Whilst the certification process used in the civil sector to approve type designs and the Airworthiness of
individual platforms clearly defines designer/manufacturer/operator responsibilities for Airworthiness, there is
not the same clarity with respect to military aircraft, where responsibility for design/manufacture/maintenance
is often shared between Industry and the IPTs and is confused.
(23) A process-dependent, paper-reliant, ‘box-ticking’ safety culture has developed in the MOD.
19.27
Any large, complex, hierarchical ‘top-down’ organisation which measures itself by strict adherence
to procedures can become a slave to process and paperwork, and find false comfort in compliance and
complexity. The MOD has not been immune from these pathogens. A process-dependent and paper-reliant
culture has developed, particularly within DE&S and IPTs, which led to a shift away from proper risk analysis
and ownership towards a ‘box-ticking’ approach to the management of safety and Airworthiness. Compliance
with process and form-filling has taken the place of sound judgment.
(24) There is too much change and not enough stability.
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There has been too much organisational ‘change’ generally in the MOD in the past decade in the wake of
the impact of the Strategic Defence Review in 1998 and subsequent Logistic Transformations. The years of
‘change upon change’ have had a baleful effect on Airworthiness systems and structures. ‘Change-weariness’
has been the most common feature of evidence given by MOD witnesses in interviews conducted by the
Review. As set out below, an internal RAF survey conducted in August 200814 found: “Near-continuous
change initiatives over recent years have created a climate of deep uncertainty, mistrust of enterprise and a
sense of ‘constant turbulence’; moreover continuous change does not permit the establishment of a baseline
to measure logistical and personnel support required to conduct operations”. Any Airworthiness system
requires time, stability, and continuity to enable it to bed down, take hold, gain strength and to become
generally understood, accepted and effective across its whole reach.
(25) There is insufficient leadership.
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With rank comes responsibility. With responsibility comes the need to exercise judgment and to make
decisions. Airworthiness judgments and decisions can often be difficult and worrying. They also can have
serious consequences. Airworthiness penumbra can also be viewed as less glamorous and pressing than other
matters. For these reasons, there has been a discernable inclination by (admittedly busy) officers at all ranks to
deflect, downgrade, avoid or slough off Airworthiness responsibility, judgments, and decisions either: (a) by
means of wholesale delegations; and/or (b) by the outsourcing of airworthiness thinking to Industry; and/or
(c) by the creation of further elaborate processes, procedures, or regulations to stand between them and the
11 Similar disquiet was voiced, for instance, in the Ladbroke Grove Rail Inquiry Report, Part 2, paragraph 7.35.
12 See further Chapter 23.
13 Airworthiness Review Certificates.
14 RAF “Capability Health Check” Survey, 18 August 2008, page A-8 (see further below).