The Nimrod Review - Official Documents

The Nimrod Review
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Recommendation 21.D.4.4: There shall be adequate funding to implement recommended
interventions.
21.90
For the avoidance of doubt, for Recommendation 21.D.4.4: (1) One of the benefits of HF (M)EMS is the
resultant smarter interventions/mitigations resulting from MEDA investigations. However, whilst many of the
recommended intervention strategies are cost effective, simple and easily achievable, a number of others
require solutions that lie outwith the Forward environment, for example in DE&S, and would require financial
commitment as ‘spend to save measures’; and (2) It is important that these interventions are assessed and
prioritised alongside technical airworthiness solutions to ensure limited resources are allocated appropriately
to reduce overall risk.
Recommendation 21.D.4.5: HF (M)EMS shall be extended beyond Engineering into a pan-Defence Error
Management System (EMS).
21.91
21.92
For the avoidance of doubt, for Recommendation 21.D.4.5: The principles of Error Management are applicable
across Defence and should not simply be confined to the Maintenance community; the obvious expansion
would be into the Operations area. However, the task of converting the current Air Command HF (M)EMS
project into a wider EMS programme should not be underestimated and would need to be carefully scoped
and project managed. The reason why the Boeing designed MEDA has evolved within the Maintenance
environment is because similar operator specific systems were not suitable for engineers.
Recommendation 21.D.4.6: There must be a commitment to cultural change at the highest level.
For the avoidance of doubt, for Recommendation 21.D.4.6: the introduction of a successful Error Management
programme in the RAF is essentially about changing current behaviours, particularly recognising that human
error is inevitable and not always unprofessional. The new ‘Just Culture’ policy lays down the ‘Code of
Conduct’ and behavioural changes that I would expect to prevail to create a just and open culture within
the RAF, and seeks to address the concerns expressed by the Chief of Defence Staff’s in his Aviate article. 41
Cultural change is key in the Air domain.
E. Single Safety Case and Single Risk Management System
Current position and shortcomings
21.93
Safety Cases (SC) have been adopted by the Military in order to seek assurance that every airborne military
platform was ‘safe’ at a given point in time against an agreed ‘baseline’ of knowledge. SCs are also used to
provide evidence to the RTSA that equipment is ‘safe’ and can be fielded to the AOAs. SCs apply to equipment
modifications. SCs are mandated by BP1201. All air platforms now have SCs. SCs are intended to be kept
current throughout the life of the platform. Many IPTs outsource the development of SCs to Industry.
21.94 A superfluity of ostensibly different types of SC has emerged in the MOD, namely ‘Equipment Safety Case’,
‘Platform Safety Case’, ‘Operating Safety Case’, ‘Operator Safety Case’, ‘Operational Safety Case’, ‘As-
Flown Safety Case’ etc. This is confusing and undermines the purpose of having a SC. Further, the volume
and complexity of the documentation that goes to make up many SCs has grown exponentially, such that
‘roomfuls’ of documents are involved which have become impossible to manage and access properly, let
alone assimilate.
21.95
The Release to Service issued by the RTSA equates to the Type Certificate that EASA issues to civil manufactures
when their designs are approved for use. Whilst the Type Certificate provides assurance that the aircraft has
been designed in accordance with approved design standards and manufacturing methods, the Release to
Service provides the Duty Holders in the AOAs with a much more in-depth assurance that the equipment is safe
41 Aviate 2007 Journal Edition – Giving Weight to a ‘Just’ Culture in Aviation by Air Chief Marshal Sir Jock Stirrup, CDS.