TIM ROBINSON reports on the highlights from the first MAA Military Air Safety Conference, held at the Royal Aeronautical Society on 24 and 25 October. [caption id="attachment_7462" align="alignnone" width="340" caption="The loss of 14 personnel onboard XV230 was a traumatic event with wider implications."][/caption] The destruction of RAF Nimrod XV230 in 2006 over Afghanistan, with the loss of the 14 lives onboard was a watershed event in the recent history of the Royal Air Force. The subsequent investigation and Nimrod Review by Sir Charles Haddon-Cave QC made for much soul searching in a military service that prides itself on its professional expertise. In short, the fire and explosion on XV230 was a preventable accident, not enemy action and should never have occurred.  But out of the tragedy and loss of life on this Nimrod and earlier accidents, the Haddon-Cave report led to the formation of the UK Military Aviation Authority (MAA) in 2010 - a new body empowered to push through a massive cultural change within the MoD and place airworthiness as the highest priority. So some two and half years after the formation of the MAA – how is it doing? Is it really changing things for the better? Is a new safety culture taking hold? The conference this week, which saw a packed lecture theatre audience of armed forces, industry, regulators and academia, was keen to find out.  

Systematic failings

[caption id="attachment_7463" align="alignnone" width="376" caption="Air Vice-Marshal 'Baz' North, ACAS, RAF is the incoming Director General of the MAA."][/caption] The keynote address at the conference was given by Air Vice-Marshal ‘Baz’ North, currently Assistant Chief of the Air Staff (ACAS) and also the incoming Director General (designate) at the MAA. The ‘horrific tragedy’ of Nimrod XV230 has a special resonance for this officer, since as commander of 83 Expedition Air Wing (EAW) in 2006 he watched the fiery remains of the Nimrod scattered over the desert via a Predator UAV imagery feed. Additionally, he also had the unenviable task of ordering Nimrod crews into the air just six hours after this loss, while the causes of the accident were still unknown. In his address, AVM North outlined the systematic failings that the Haddon-Cave report had identified in the MoD’s approach to aviation safety and airworthiness. It (and the contractor) had been sloppy and complacent, despite warnings. Box ticking had replaced intelligent risk management and, most damningly of all, the RAF (& MoD) had “outsourced its thinking” on safety and airworthiness. A culture of muddling through and wrong assumptions had, over time, allowed the services to lower their guards against the potential dangers. So why had this happened? AVM North noted that since the late 1990s there had been massive organisational shifts and reorganisations in the MoD, confusing and blurring lines of responsibility. In addition to bigger ‘purple’ fiefdoms, there had been an expansion in outsourcing and a focus on commercial aspects. These contributed to the loss of corporate knowledge and inability to recognise the risks that were building up.  This and other flaws were highlighted by Haddon-Cave in his report which focused not only on the Nimrod accident, but on the wider safety culture. Following the publication of his report in 2009, the MoD accepted the findings and moved to implement the majority of his recommendations, including bringing in a new safety culture. The vehicle for this would be the MAA.  

Independent or not?

[caption id="attachment_7464" align="alignnone" width="376" caption="Air Marshal Timo Andersion, Director General, UK Military Aviation Authority."][/caption] Speaking at the conference, the current Director General of the MAA, Air Marshal Timo Anderson reaffirmed that the Haddon-Cave report was 'shocking and deeply uncomfortable for anyone in the MoD.’ He explained how the MAA had been created as an independent military air safety authority from scratch and with ‘no script’. So what is military air safety? Is there such a thing anyway when military aviators can operate their aircraft in a way that the civil world would regard as 'dangerous', such as low level, at night and perhaps with an enemy trying to kill them? Anderson explained that the new definition of military air safety includes the traditional ‘airworthiness’ and ‘flight safety’ aspects but also ‘policy’ and ‘apportionment of resources’. Crucially though, military air safety does not include ‘survivability in hostile environments’ or more bluntly, enemy action.  In his presentation, he refuted critics that the MAA is not independent. The MAA Charter from the Secretary of State for Defence, he says, allows him to “go anywhere, ask anything.” In addition, Anderson says that there are no service chiefs in his chain of command – he reports directly to the SoS. This means that the MAA is “99.5% independent” from the MoD, according to Anderson. This fierce independent status has already earned him “scars and bruises from speaking the truth to those in power.” In one instance he said that he got a requested intervention at the very highest level. In another the MAA highlighted safety measures needed for rotorcraft which resulted in this issue being propelled up the list of priorities. Finally he gave another example where out of service dates, again for an unspecified platform(s), are now dependent on MAA endorsement.       In short, while it may still exist as a body within MoD, the directive flowing right from the top via its charter means that there now seems to be little chance that ‘raised eyebrows’ could stall or deflect the MAA from its air safety mission. As one senior officer noted of any dissenters to safeguarding airworthiness - telling them to “put it in writing for me” quickly nips these in the bud. These inbuilt “constructive tensions”, as Anderson describes them, prevents any kind of cosy relationship developing. Would the MAA be any more powerful if, as a regulator, it were fully independent outside the military? Perhaps, but perhaps not. It would, however, according to one source, suffer a problem of credibility. Military aviation is subtly different from civil aviation and having the MAA comprised of those with a deep and insider’s knowledge of the risks and operational necessities of service aviation allows it to talk and advise on equal terms with those responsible for implementing safety.  Said Colonel Mike Smith AAC, head of the new Military Air Accident Investigation Branch (MAAIB) set up in 2011 on this being attached to the regulator: “If we were outside, they would talk to us, but they wouldn’t engage.” Smith pointed out that with support (and close day-to-day contact) from the UK's civil AAIB, as well as other external groups such as aviation medicine, materials integrity group, flight data analysis and industry, the MAAIB already enjoys much independence. In addition, he explained that the MAAIB and Service Inquiry team for any accident does have a final option of reporting directly to the MoD Permanent Under Secretary. This ‘nuclear option’ has not been used yet but is a safeguard against conflicts of interests where the ‘decisions or activities of the regulator are investigated’.      

The role of Duty Holders

[caption id="attachment_7465" align="alignnone" width="376" caption="AVM Phil Osborn, AOC, No2 Group, RAF describes the weighty responsibility of being a Duty Holder."][/caption] A key part of the MAA’s success so far, it seems, has been the concept of ‘Duty Holders (DH)’  a second parallel chain of responsibility that is separate from the operational chain of command. As Air Vice-Marshal Phil Osborn, AOC No2 Group, who is a Duty Holder notes, the “command chain enables air capability, while the Duty Holders chain enables air safety”.  These Senior (chiefs of staff) and Operational Duty Holders (eg: base/group commanders) are few in number but are charged with personal and legal accountability in upholding air safety in their domain. They also have great power and can order (and have done) aircraft grounded if they suspect there is an issue which needs resolving. This responsibility is simultaneously frightening and empowering. Osborn noted that as Duty Holder for No2 Group he was responsible for around “250 high or catastrophic risks” – (or in plain English aircraft and helicopters). Motivation, then, is not a problem.  As one senior officer quipped of the wording of ‘personal and legal accountability’: “It scared the life out of my wife, and anything that scares the life out of her I attend to.” Joking aside, the concept of Duty Holders means that in effect, any scapegoats or guilty parties for future air accidents or airworthiness disasters have already been pre-identified. No longer can responsibility be ducked, passed on, or shoved under the carpet in the manner of earlier controversial incidents. Osborn argues, too, that: “Empowerment is to be embraced – it makes me a better commander.” The Duty Holders work hand in hand with the MAA Audit programme which sees audit teams that revisit units and commands ranging from less than six months to 24 months depending on the risk identified and the measures needed to resolve it. ‘Serious weaknesses’ (red category), for example, means a revisit time of within six months, while ‘no weakness’ gives a revisit time of between 18-24 months. These regular MAA Audits allow ‘auditable risk-based evidence for strategic decisions and  prioritisation of resources’. They also crucially allow DHs to publically articulate and raise risks which are not ALARP '(As Low As Reasonably Practicable) or cannot be mitigated’.  Finally, as noted above, the DH can also mandate cessation of flying activities. This has the result of getting everyone’s attention until the issue is addressed.        

Revitalising professional engineers

[caption id="attachment_7468" align="alignnone" width="187" caption="There has been a new focus on professional development and recognition for those involved in airworthiness. (RAF)."][/caption] Another interesting aspect from the conference was the revitalisation of the Armed Services engineering career path. The post of RAF Chief Engineer was reinstated and at the event, the current holder of that post, Air Marshal Simon Bollom DE&S Chief of Material & Chief Engineer, RAF, explained how he was implementing and promoting ‘increased professionalism’ in airworthiness roles. New DE&S regulations, for instance, require airworthiness post holders to be CEng or IEng. Specific training/experience for certain posts is also now required. In addition, a focus on SQEP (Suitably Qualified and Experienced Persons) means the MoD is now urging those engineers involved in airworthiness to consider accreditation and professional development schemes such as those run by the Royal Aeronautical Society and the IMechE. The theory is that if those involved in airworthiness do invest more in gaining accreditation and professional recognition, this will be a key line of defence against personnel ‘churn’ and losing corporate knowledge in the future.                  

External audit

[caption id="attachment_7467" align="alignnone" width="177" caption="Changing a safety culture is more than extra safety posters (MoD)."][/caption] However, despite the worries over self-regulation, part of Haddon-Caves recommendations included the need for an external audit of the MAA and its progress. This review, the MAA External Audit Panel (MEAP) which was carried out by the representatives of the UK’s CAA , Health and Safety Executive, The Netherlands MAA and even a pilot from the US Navy, reported in May. It also specifically excluded serving or past members of RAF or other UK services as well as anyone connected with the Nimrod report. It found that: “In response to Mr Justice Haddon-Cave’s (H-C) Nimrod review, the Military Aviation Authority (MAA) has rapidly and purposefully started to recalibrate the military air safety regime in its first two years of activity. There is strong evidence that the key dutyholder concept is well understood. The building blocks to address and eliminate the frailties in the system are being progressively established. There is still significant work to do further to embed the changes but the right direction and tempo has been set.”          However, the MEAP did identify ‘areas of residual risk’ ongoing for the MAA. These include ‘the department stops short of full implementation of H-C’, the ‘MAA not making best use of available data’, the ‘regulated community falling back into old habits unless the regulatory pressure for behavioural change persists’ and ‘the MAA not addressing or measuring the right things to gauge wider improvements in safety’...   What if, the MEAP asks, the ‘cultural changes recommended by H-C do not materialise?’ – due to the “ingrained and muscle-bound culture being impossible to change”, according to one speaker. Despite these concerns, the head of the MEAP audit, David Snowball, from the UK’s Health and Safety Executive (HSE) said it was a “very positive finding”. In particular, at the conference he praised the MAA’s use of data, its “gold-plated approach to accident investigation” and the fact that the MAAIB was “not an underranked organisation”. This issue, of having sufficient ‘top brass’ on your team to provide ‘bureaucratic firepower’  in a hierarchical organisation was lamented by the Dutch MAA speaker, Air Cdre Chris Lorraine who noted that defence cuts in The Netherlands are set to reduce his post’s rank.  In contrast, the DG of MAA is a 3-star post. The MEAP audit also confirmed that AVM Anderson’s comments about gaining “scars and bruises” through interventions on behalf of the MAA have already had an impact on flight safety issues. It reported:  “The MAA can point to specific impacts on MoD planning and budgeting decisions on air safety grounds where the safety ‘flag’ has been influential. They include a reprieve of the Tornado Collision Warning System programme and engagement on behalf of rotary wing safety measures such as airborne collision warning and wire strike protection.” The critical questions to ask on judging the MAA’s success, said Snowball, were: “What difference have you made, and how do you know?”            

Challenges

[caption id="attachment_7470" align="alignnone" width="374" caption="The introduction of the Rivet Joint-based Airseeker could pose special challenges for the MAA. (RAF)."][/caption] There thus still remain challenges in this huge task of changing an entire organisation’s safety culture. As AVM Anderson notes: “There is more to it than flight safety posters in the loos.” For one, the MAA has undoubtedly increased the workload on hard-pressed operational units. Indeed, one question from the floor said the ‘distraction and dilution’ was worse now than before.  Additionally, the conference audience heard the issue of defence cuts meant that the DE&S was set to lose some 25% of its staff – just when the MAA was attempting to promote the retention of professional engineers and airworthiness specialists. There, too, is also the need to be flexible. One speaker noted that the RAF’s new spyplane, the Airseeker, presented unique challenges as a ‘hybrid’ of an older US (KC-135) airframe and newer electronics – which might mean missing or ‘lost evidence’ in the audit trail. Smaller manufacturers, who may not keep the same standard of records as larger firms, too, could also present this problem which the MAA will have to address.    Finally, there is the underlying concern from some quarters: has ‘risk to life’ become the only currency in UK military aviation? In short, could the ‘health and safety culture’ derided in some sections of the British press under headlines such as ‘children banned from conkers’ set to adversely affect military capability going forward? The signs seem to indicate not, but it is still worthwhile asking the question. As one speaker noted, risk can be tolerated but it must deliver a benefit. An example is parachute training which can result in broken limbs etc in practice jumps, delivers a larger operational benefit in terms of military capability.  

Summary

[caption id="attachment_7466" align="alignnone" width="376" caption="The MAA has already flexed it muscles to reverse an earlier decision on Tornado collision warning systems."][/caption] Since its inception, the MAA has come in for a fair deal of criticism. Some argue that the body is still a case of self-regulation, which has been proved not to work. Others may point at the extra work and challenges it generates for those at the sharp end and its intrusive nature in its fledgling state. Yet there appear to be definite signs of progress in the massive task of changing the MoD safety culture. "We've done a lot" says AVM Osborn, "far more than people probably perceive" on MAA changes. This view is echoed by the head of the MEAP external audit, David Snowball, who commented that the auditors were surprised at the pace of progress, saying: “How did they manage to move so quickly in two years?” The body is moving to become more proactive, more focused and less intrusive, while still communicating to all in MoD that, in the words of one speaker: “there is an animal in the forest.” What is more is that the empowerment of Duty Holders in fostering safety at all levels has found a receptive audience. Says Osborn: “Our people have a voracious appetite for this and for doing the right thing. They ‘get it’.” In particular, while there have been other accidents, the tragedy of Nimrod XV230 has become a crusade for those involved in military air safety, stimulating a faster pace and deeper change than a traditional paper-shuffling-led reorganisation might engender. From this conference, it seems, while there are certainly more battles to come, the MAA seems to be slowly winning the war.

Tim Robinson
26 October 2012