The Nimrod Review - Official Documents

Chapter 21 – New Military Airworthiness Regime
organisational boundaries (e.g. IPT to AOA); (3) All platform risks and the associated mitigations shall be
managed and reviewed in order to uphold and document decisions that the specific risks are ALARP; and
(4) If a platform has a significant risk that cannot be mitigated, it should be possible to trace that risk from
platform-level to the appropriate rank/individual where it has been accepted, i.e. traceability from platformlevel
through to the DESB.
Recommendation 21.E.5: The Regulator shall provide independent assessment of Defence Airworthiness
risk management.
21.106
For the avoidance of doubt, for Recommendation 21.E.5: the Regulator shall ensure coherence across the
air domain as well as regulatory compliance in a similar manner to the Australian Defence Force, which
undertakes an annual independent review of Airworthiness risks across all Defence Lines of Development.
Recommendation 21.E.6: The Regulator shall undertake a review of the certification process for
military aircraft in order to align the Airworthiness assurance processes used by the three Services and
to establish clear lines of accountability for the design, manufacture of aircraft types, and continued
Airworthiness of specific platforms.
21.107
For the avoidance of doubt, for Recommendation 21.E.6: the review shall consider the benefits of the civil
certification system, and the requirement to review the Airworthiness of individual aircraft or fleets annually,
considering all of the Defence Lines of Development that contribute to the Airworthiness of a platform.
Recommendation 21.E.7: The Regulator shall devise and stipulate a simple, common Hazard Risk Matrix
which is to be used across Defence.
21.108
For the avoidance of doubt, for Recommendation 21.E.7: given the myriad of Hazard Risk Matrices that are
used to determine risk categorisations, the Regulator shall devise and lay down requirements for a simple,
common Hazard Risk Matrix which: (a) comprises no more than a 4 x 4 matrix grid (to encourage intelligent
assessment over subjective and prescriptive numerical assessments); (b) provides a system for pro-actively
managing all risks that fall under the ‘catastrophic’ heading where assessments on likelihood are often based
on small samples; and (c) provides for meaningful comparative assessments to be made between platforms
(this requires a common data format to be defined at the lower level, i.e. individual platforms, so that the
higher-level register can extract relevant risk data from IPT/AOA hazard logs).
F. New Joint Independent Accident Investigation Process
Current position and shortcomings
21.109
44 See JSP832.
The Service Inquiry (SI) process for investigating military aircraft is based on Boards of Inquiry (BOI) convened
by the relevant AOA. 44 The AAIB is normally invited by the AOA to undertake the technical aspects of the
investigations unless the aircraft is embarked, or deployed, in an operational theatre, in which case the RN’s
own accident technical investigation team undertake that role. Presidents of BOIs and their fellow board
members are nominated within a few hours of an accident occurring, and usually comprise a senior aircrew of
Wing Commander rank, supported by another aircrew member and an engineering officer, both of Squadron
Leader rank. The officers involved would normally have recent experience of the aircraft involved, but would
not be associated with the Squadron concerned. The SI team would be advised throughout by a full time
trained Inquiry specialist from the Flight Operations Regulator’s team (DARS) who would advise on protocol,
process and provide links to the relevant specialists’ organisations. The publication of the Inquiry report may
take over a year, due in part to the extensive high level staffing that is undertaken prior to publication. Once
the report is issued, BOI members are increasingly likely to be involved in the civil scrutiny which further
extends their involvement. BOI reports attempt to identify the cause of the accident but no longer apportion
blame. The SI process is now aligned across the three Services.
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