|Last Updated: Mon Jan 27 11:18:09 UTC 2014|
Ending Story of Airworthiness versus
Air Power Australia Analysis 2007-04
12th November 2007
by Air Commodore Ted Bushell AM (Retd)
Text © 2007 E. J. Bushell
Westland Sea King HAS 50/50A (C. Kopp).
Before the structural changes that swept through the Services during the 1980s, the RAAF had, at its highest organisational level, a Chief of Air Force Technical Services (CAFTS) whose major responsibility was to ensure that the aircraft operated by his Service were, amongst other major requirements, safe to operate; that is, they were technically airworthy. The CAFTS Branch was most successful in establishing and maintaining the policies, systems, and procedures that ensured that all of the elements that combine to ensure technical airworthiness visibility and control were in place and functioning properly. The RAN, through its Chief of Naval Technical Services (CNTS) had similar responsibilities for the management of naval technical equipment. Army, the least technological of the Services, placed Technical Services at a lower level of importance than Navy and Air Force.
From 1989, the Service Technical Chiefs and their staffs were disbanded, and the coherent policies, systems, and procedures, built up over decades of experience, were dissipated and largely lost. Since then, we have seen several avoidable disasters that can be traced to the loss of sound technical management within the Services, the latest being that covered by the Board of Inquiry report into the Sea King Tragedy.
While the Inquiry into the Sea King Tragedy uncovered much evidence, the required technical expertise and experience was not available within the Board or in the Services for it to identify the root cause - the structural deficiencies that have been embedded within the Services, largely by Government and bureaucratic decree. As a result, the Inquiry was not able to come to a properly-defined root cause or a properly-defined set of recommendations, which also points to inherent shortcomings in the use of such boards for this purpose. In the end, the promise by the Chief of Defence Force to implement all the recommendations of the Inquiry, and so cure the ADF's problems, will be proven, inevitably, to be hollow.
The overview that follows will, hopefully, give those not familiar with the chain of technical airworthiness some awareness of what is involved in ensuring that disasters such as the Sea King Tragedy do not, within human limits, occur in military aircraft operations.
Airworthiness in its widest sense is a condition of flight safety measured by the combined effectiveness of the policies, systems and procedures in place and managed by operational and technical staffs working together closely.
Maintaining aircraft in a condition safe to fly has, since the beginning of flight, been a constant battle of wits between those responsible for the management of technical airworthiness and Murphy , who is ever alert to take advantage of the slightest relaxation in technical airworthiness policies, systems, and procedures. When he penetrates the defences of technical airworthiness management, the results are often fatal for those involved.
The meaning of technical airworthiness is recognised by few people, particularly in terms of how it is achieved and maintained over time within a military environment. In simple terms, technical airworthiness comprises a number of closely linked activities that must be in place and adhered to if the technical safety of aircraft operations is to be assured. Should any activity be missing, or be weak, then airworthiness management will be prone to failure and Murphy doesn't usually let such occurrences pass him by unnoticed or unpunished.
The technical policies, systems and procedures required to be in place to assure the safety of flight of military aircraft also apply generically to the RAN in ensuring that its ships and submarines are seaworthy. The 'Westralia' disaster brought home the penalties of default in seaworthiness management dramatically, in this case a simple breakdown in the technical management of the configuration control of high pressure fuel hoses. Unfortunately, for all the words written, the real cause, that is the root cause, was not identified - the disbandment of the Navy's Engineer Branch and with it the loss of the Navy's policies, systems and procedures for managing technical seaworthiness. However, this paper will concentrate on the RAAF and its responsibility for the technical airworthiness of ADF aircraft.
An ABC of RAAF Airworthiness Management, Pre-1988/89.
Before the structural changes of 1988/89, the technical airworthiness responsibility for RAAF, and some Army and Navy, aircraft rested with CAFTS, an Air Vice Marshal who reported directly to the Chief of Air Force. CAFTS' staff were organised broadly into Engineering, Maintenance, and Quality Assurance directorates, with close interfaces forged with the Supply function to ensure that only technically approved parts entered the RAAF's inventory, an important element in airworthiness control as Murphy prefers to use small and inexpensive items to cause havoc.
Regrettably, government-driven changes led to the disbandment of the Engineer Branch in the RAAF which, with the sweeping organisational changes that followed, resulted in a wide range of highly successful policies, systems, and procedures, built up over some 70 years of experience, being largely lost. In short, the CAF had lost visibility and control not only of his technical resources, but also the airworthiness state of his fleet and that of the other Services.
As a result of growing disquiet over maintenance standards in the RAAF, the CAF directed a detailed review be undertaken in 2006. The recommendations of that review were accepted recently in toto. As a first step in regaining visibility and control, CAF has established the post of Director, Maintenance Policy and Planning-Air Force with a wide-ranging set of responsibilities. This move, given adequate priority, manning and support, should go some a significant way towards regaining visibility and control of some technical functions. The position of Director-General: Maintenance was one of those disbanded in the deconstruction of the Engineering Branch in the late 1980s/early 1990s. However, maintenance is but one function impacting technical airworthiness. There are others that must also be gathered in if a strong chain of technical airworthiness control is to be re-established within the RAAF.
Airworthiness is usually re-defined as each generation of 'nuveau management salesmen' emerge, with each new definition being more obscure and verbose than the preceding one, indicating a loss of depth of understanding on the part of each new generation of managers. A simple definition of technical airworthiness used by the RAAF was:
In practice, technical airworthiness is the sum of well-integrated and focussed engineering, maintenance, and supply functions which form an unbroken chain to provide the visibility, monitoring, control, direction, and development of technical airworthiness standards. Unfortunately, the current organisation of the ADF, and particularly that of the RAAF, makes it impossible for the RAAF to assure the airworthiness of its own aircraft, let alone all ADF aircraft, without significant structural change.
The Technical Services Function.
Broadly, the responsibilities of CAFTS related to the specification of engineering standards and technical airworthiness control of all RAAF technical equipment, excluding civil works. These activities were directed at ensuring that RAAF aircraft and their weapon and support systems, including some Army and Navy equipments, were capable of performing their operational role safely. However, the RAAF knew from hard-won experience that its weapon systems must not only be operationally capable, that is, that their structure, flight controls, navigation systems, weapons, etc, functioned properly, but:
These functions were managed in turn through three main directorates – Engineering, Maintenance, and Quality Assurance.
The Engineering Function.
Engineering standards were established and varied as necessary through a chain of activities, mainly:
Technical Requirements Specifications (TRS). These ensured that aircraft and other technical equipment were designed and manufactured to approved standards before being accepted into the RAAF. Sections of the TRS related to reliability and maintainability requirements which drove maintenance policies and support requirements. The Specification was an important baseline document that defined the need for many subsequent technical management activities.
Configuration Control. This is the most important link in the airworthiness chain. An aircraft's configuration baseline must be established as part of the procurement process and amended to reflect all changes introduced over its Service life. If an aircraft's configuration, down to every item classified as a configuration managed item, is not recorded correctly and kept current, then Murphy is free to act at will. The configuration of each aircraft was recorded in a Technical Management Plan (TMP), which was also the baseline document to which all maintenance policies and support requirements were keyed through a Technical Management Code (TMC). This code identified each configuration item in terms of the aircraft, system, and sub-system to which it was fitted. It was also the data base identifier against which defects and failures were reported, recorded, collated, and analysed. In the absence of an accurate and current configuration record, technical management and hence airworthiness visibility and control are not possible.
Technical Support Policy and Requirements. The aircraft's TMP was also the repository for the maintenance policy and support requirements for each configuration item, by stating:
The engineering function not only established the standards needed to assure effective operational support, but monitored the chain of technical airworthiness activities to ensure that they were appropriate, in place, and functioning correctly.
The Maintenance Function.
While Engineering was concerned with establishing policies and monitoring and varying technical standards, Maintenance was involved mainly with the continuing management of the activities associated with getting operational aircraft (and their supporting systems) on line and keeping them there. The Maintenance function was conducted:
At the flying units, the point at which operational and technical requirements interface, conflicting demands can arise during periods of high operational tasking, and particularly when operating away-Base. Resolution of these conflicts requires a sound and mature understanding on the part of the operator of the role and importance of scheduling aircraft for flying and maintenance so as to keep a well-controlled aircraft maintenance stagger. The maintenance element, for its part, needs to be able to respond flexibly to periodic, high operational tempo, while ensuring that maintenance work does not come under unsafe pressures, and any work backlogs do not give rise to rushed and unsafe catch-up maintenance. The Unit Maintenance Control Section was designed to resolve planned flying and maintenance matters in a well-coordinated manner, but it requires sound operational and maintenance management skills for it to be successful. The operational/maintenance interface, when under pressure, will always carry the greatest potential for Murphy to wreak havoc.
The maintenance function not only focussed on operational support, but provided a critical feed-back loop so that problems and changes that may distract the maintenance element from its prime focus could be analysed and corrected 'off line' by engineering. It also forms the interface for the proper and safe planning of flying and maintenance within constrained resources.
The Quality Assurance (QA) Function.
During the 1990s, the aviation quality assurance function was removed from the CAFTS Branch to a central QA bureaucracy together with similar functions from the other Services. Here, the function was totally run down and de-skilled, destroying the quality defences that had been built up to constrain Murphy.
Technical Services Functional Interfaces.
Engineering and Maintenance functions required close and continuing interfaces with a number of other areas, mainly:
The management approaches described not only provided sound technical airworthiness control, but provided a very good capability to identify departures from required standards, and hence provided the ability to correct them before they impacted technical airworthiness. The most damaging foray by Murphy post-WW11 occurred during the Vietnam period when the RAAF had to expand its operational effort under serious resource constraints. That story, which resembles the Sea King Tragedy in many respects, is given at Attachment 1. Of importance, is the manner in which the Chief of Air Force Technical Services at the time was able to marshal his resources, manage the problem, and solve it promptly and effectively, a far cry from the 21 month long Sea King Inquiry!
It is not proposed that the CAFTS organisation be re-introduced into the RAAF, as structural changes preclude that. There is an urgent requirement, however, to re-establish a strong Technical Services organisation within the RAAF, and the other Services as appropriate to their operational roles and technology base, if proper control of the technology operated and supported is to be regained.
The loss of the policies, systems and procedures that assured sound technical management and hence technical airworthiness control were dissipated and largely lost as a result of waves of structural changes, internal and external, that have swept through the RAAF. Some of the most important were:
The RAAF Reorganisation of the 1980s. The RAAF, as a result of the protracted inability of the Defence bureaucracy to obtain the resources needed to maintain even minimum Service capabilities, was forced to reorganise its support functions. Essentially, this involved the delegation of many of its Support Command functions down to Unit level. The planning for this was based on the assumptions that the Command would retain an oversight function and that the Engineer Branch would remain at Air Force Office. Unfortunately, both of these assumptions were overturned by subsequent Government-driven changes that resulted in the focus of the Air Force reorganisation being lost.
The 'Sanderson' Review of 1989. This review led to the disbandment of the Engineer Branch in the RAAF, and in turn a widespread technical de-skilling. It also resulted in the creation of a wholly inappropriate organisational structure at Air Force Office. About the same time, the RAAF introduced a 'General List' for senior officers which resulted in 'generalists' taking decisions in areas where they lacked the necessary technical knowledge and experience. The General List also contributed to a drastic reduction in the depth of the RAAF's knowledge and experience base in all areas and at all levels.
The Commercial Support Programme, Defence Efficiency and the Defence Reform Programmes. The changes introduced by these programmes, and the interminable reviews that followed during the years that followed, not only completed the technical gutting and de-skilling of the RAAF, but introduced structural, organisational, functional, financial, and language barriers that made it impossible for the CAF to manage the RAAF as a force, or able to guarantee the RAAF's own, let alone the ADF's, technical airworthiness standards. Limiting the establishment of the Service Offices to an arbitrary 100, without regard for the marked differences between them in operational, technology, and support areas reflected gross ignorance at best. Some examples of the impact of these changes on the RAAF's technical competence follow:
1992-94. Support funding for in-Service aircraft was curtailed severely. Mandated reductions in military and civilian numbers occurred using the CSP as the target saving mechanism. Recruiting and training of the technical workforce was reduced from 1,100 to 400 per year, which created a 'black hole' in technical capabilities that persisted for a decade and left the Service with a much less competent technical workforce than existed before.
1991-97. The CSP also saw the RAAF's three aircraft depots commercialised, wholly or partly, resulting in some technical trades becoming non-viable. Engineering, Logistics, Administration, and Training establishments were reduced to meet mandatory savings of 20% for technical activities and 40% for the others (which also supported the technical function). Savings were reaped from the RAAF budget annually by Defence Central Finance, without reconciliation with the impacts on capabilities, including airworthiness management.
1998 to Today. This period saw, amongst many other changes, the Services' Support Commands taken over by Defence and absorbed finally into the DMO, an ever-growing bureaucracy, remote from the needs of the Services and responsive to other than Service needs. Many reviews and reforms have taken place with the aim of improving equipment procurement processes, but none has proven to be the panacea promised. Major mistakes that impact Australia's force structure and Service capabilities are still being made and highlighted, but the organisation seems incapable of improvement. No change seems to stem from what is best for the Services, including their capability to assure airworthiness.
The disbandment of the Engineer Branch, the imposition of an inappropriate structure for the management of the RAAF, the introduction of the General Branch and the continuing impacts of the CSP and DRP all lie at the very heart of the problems being faced by the RAAF and, in turn, ADF technical airworthiness management. It follows that those changes must be reviewed and discarded or severely modified where they have caused unacceptable damage.
In short, the technical airworthiness chain was seriously weakened, then broken up. Visibility and control of the chain was lost and has remained largely lost to the Chief of Air Force.
The seeds were sown for the problems now entrenched throughout the RAAF, and, in general, for military flying throughout the ADF.
Not surprisingly, the outcome of these changes led to a fragmented engineering and maintenance organisation with limited strategic guidance, a poor sense of direction, inadequate visibility of technical workforce matters, failing performance management, and little ability to plan for the future. (A RAAF assessment of 2006.)
The Perceived Airworthiness Solution.
During 1990, and largely in response to a series of aircraft accidents, a regulated system of airworthiness management was instituted which led to the development of the ADF airworthiness arrangements in place today. At the top, the Charter for the Chief of Air Force states: 'act as the Australian Defence Force airworthiness authority'. The system adopted was based on the CASA/FAA approach, modified substantially to meet the particular needs of Defence Force aircraft, but considered to be sound.
However, while a regulatory system may be sound, its effectiveness depends entirely upon how it is managed, the degree to which it is understood throughout the ADF, and the manner in which each Service implements the regulatory requirements.
Under the CAF, as the Airworthiness Authority, a Director General of Technical Airworthiness-ADF (DGTA-ADF) was formed in 1998 with a tri-Service focus on technical airworthiness matters. However, it must be understood that he is not responsible for the efficiency or preparedness aspects of Air Force aviation maintenance, or a wide range of ground-based Air Force technical equipment, or for similar areas in Navy and Army. The DGTA role is solely that of a regulatory authority of technical airworthiness.
Unfortunately, the lack of an agency in either AFHQ or HQAC with responsibility for RAAF maintenance has led to the placement of some technical workforce management functions with DGTA-ADF, even though they do not and should not fall within his responsibilities. (A RAAF assessment of 2006.) The same situation has, unfortunately, also developed in Navy, as evidenced by the Sea King Inquiry, and in Army.
In effect, the DGTA-ADF organisation is seen by many to be both a regulatory authority and an implementing authority. In fact, his activity represents only part of the total management activity associated with technical airworthiness. The fault and consequences for this situation can not be sheeted home wholly to the organisation. They have to be sheeted home primarily to the chain of ill-considered structural and resource changes that created the present situation and the appointments within those Defence and Service organisations that allowed them to happen and to continue unchecked.
The core of the problem lies in the absence of a coherent technical organisation within Army, Navy, and Air Force with responsibility for the establishment and maintenance of the policies, systems, and procedures necessary for the proper management of all technical support activities, including technical airworthiness.
The US Navy (USN) Tarawa Class Amphibious Assault Ship USS TARAWA (LHA-1) pulls alongside the Royal Australian Navy (RAN) Durance Class (Underway Replenishment Tanker) (AORH) Her Majestys Australian Ship (HMAS) SUCCESS (OR 304) to prepare for a replenishment at sea (RAS) in support of exercise Rim of the Pacific (RIMPAC) 2004. A Westland Sea King HAS 50/50A sits on the rear deck of the SUCCESS (US Navy Image).
THE SEA KING DISASTER AND AIRWORTHINESS MANAGEMENT
The Defence Media Unit advised in mid-June of this year that the Board of Inquiry into the Sea King Accident of 2nd April 2005 had been submitted to the Fleet Commander as the Convening Authority on 18th December 2006, some 21 months after the event. The media release goes on to say, somewhat proudly, that:
On receipt of the Report, a Board of Inquiry Implementation Team distributed the Findings and Recommendations to 27 Implementing Authorities to assess how the Recommendations could be implemented, identify the resources required, and establish the estimated completion date. It seems that 30% of the Recommendations have reportedly been completed and another 60% will be implemented by December 2007.
The Media Release ended up by assuring all that:
"By improving aviation safety, Navy and Defence demonstrate that it has learnt from this tragedy".
Unfortunately for our military aviators and all those who fly with them nothing could be further from the truth. We now await Murphy to select the next tragedy and await the next judicial Board of Inquiry, as the root causes of the Sea King Tragedy have yet to be identified and acknowledged, let alone accepted and corrected by the Defence Organisation.
Root Cause Analysis.
When performing a formal Root Cause Analysis, it is generally found that there are several levels of 'causes' between the 'Primary or Initiating Cause' and the 'Root Cause'. In practice, these can vary from four to ten levels, depending upon such variables as the number of levels of management involved with the failed item (or incident), the type of failure, and the extant risks that, because they had not been retired or mitigated, led to the failure. In the case of the Sea King Tragedy, the Primary Cause was a technical failure of the bell crank assembly, induced by the absence or failure of the split pin required to secure the nut. As in most cases, the Root Cause continues to exist well beyond the Primary Cause and has done so for some time.
The 256 Recommendations.
The simple fact that the inquiry saw 256 Recommendations as being necessary to 'fix' the problems impacting but one accident, the primary cause of which was readily identifiable, should have raised loud alarm bells. How could so many things be found to be so bad in so many different areas and require so many corrective actions? Surely the Board was telling itself that effective technical management within the Services, not only technical airworthiness management, was missing, and that this was the problem that should have been scrutinised. A technical Root Cause Analysis (RCA) was plainly required to get to the bottom of the problem. However, this obvious conclusion escaped the Board and, so, it merely prescribed the application of 256 Band Aids to cover those symptoms that the Board saw as 'relevant'.
Here, it should be noted that the Board dealt with only one aircraft and one accident. Had accidents over the past decade been reviewed, as suggested by the original Terms of Reference, the findings and recommendations would probably have totalled several hundreds more. This would have given a better idea of the scale of the core problem. However, even then the scope of the problem would not have been fully in focus, as we would need to add those systems and equipments that support aircraft operations - these also have to come under firm technical management within each Service if we are to assure proper technical safety of air and other operations.
The 27 Implementing Authorities.
Similarly, in identifying that 27 different authorities were involved with the 'management' of the technical airworthiness of the Sea King, the Board should have paused to ask if such an arrangement was an efficient and effective way of managing such a critical aspect of Australia's military airpower. How can safety of flight be assured when those involved have to manage across 27 organisational, functional, cultural, and financial interfaces? This situation again drives home the absence of any coherent technical management organisation within the three Services, a situation which seems to have slipped past the Board's notice.
The table following identifies the areas that have been called upon to take 'corrective' action. In many cases, the authority responsible for taking action has been called upon to liaise with several other areas involved, adding further levels of complexity in coordination. Prima-facie, the number of Recommendations that fell across the interface between the Maritime Commander and COMAUSTNAVAIRGRP should have been seen as particularly important red flag.
None of the Recommendations demonstrate any understanding of the technical airworthiness chain discussed earlier, which in turn indicates a lack of appropriate operational and technical knowledge and focus on the Board. In the end, the Board was unable to see how much of the chain was missing or broken, and so in turn was unable to realise that its Recommendations could not result in fundamental or lasting improvements in establishing and maintaining an effective technical airworthiness chain. This calls into serious question the usefulness of a legal-centric process to investigate wholly operational and technical matters. Disciplinary considerations should always follow the results of an operational/technical inquiry.
The Role of DGTA-ADF.
In some of its Recommendations, the Board drew close to the nub of the problem, when it voiced a general unease with the higher management of airworthiness, but then it shied away and simply called for someone to conduct some wider reviews, mostly the DGTA-ADF. Some examples are contained at Recommendations 14.1, 14.4, 14.6, 14.7, 14.12, 14.16, 14.17, 14.21, 14.26, 14.28, and 14.29.
More importantly, in other Recommendations, (such as 7.2, 7.4, 7.7, 8.8, and 10.7) we see DGTA-ADF being called upon to provide such services as engineering and maintenance advice to units, become involved with the amendment of technical publications, conduct maintenance performance audits, become involved in maintenance management, and also with training and maintenance regulations – all technical management functions that reside within Navy. However, these have flowed into the serious observations contained in Chapter 4 – Annex B – Summary of Findings, B14.1 to B14.5.
Recommendations such as these highlight a very serious problem with the Inquiry, which is the Board's assumption or interpretation of the nature and scope of the responsibilities of DGTA-ADF. The report and its Recommendations assume, quite wrongly, that all these functions fall within the responsibilities of DGTA-ADF. They do not, and it is quite wrong to saddle him with them. To do so would place him in a position of gross conflict of interest and task him with responsibility for Service management activities over which he has, rightly, absolutely no authority.
DGTA-ADF is a regulatory body and is thus responsible for the proper regulation of ADF technical airworthiness. He is not responsible for engineering or maintenance management. These are a user Service responsibility.
DGTA-ADF must not be seen as a panacea for the Services' fundamental technical management deficiencies that were imposed largely by Government and bureaucratic decree.
The problem is that none of the Services has any technical management organisation able to take up technical airworthiness matters, apart from the RAAF's embryonic Director of Maintenance Policy and Planning.
In short, the Board demonstrated an inability to get to grips with the technical airworthiness management chain and to allocate management responsibilities to the correct authority.
The RAAF's Court of Inquiry Methodology.
The RAAF's traditional way of handling accidents, such as the Iroquois problems outlined at Attachment 1, was characterised by:
A Court of Inquiry process, with the President and Members drawn from across the Service (and from outside when necessary) to ensure that the inquiry had the span and depth of experience and expertise needed.
Terms of Reference that focussed sharply upon what happened and the root cause(s).
A Clear identification of any corrective action required, by operational, technical, and other staffs.
Prompt action, as any unwarranted delay could well result in a continuing risk.
The Court of Inquiry process also formed a vital feed-back loop for operational and technical managers, especially in the area of airworthiness management.
In short, the RAAF dealt with Category 5 and/or fatal accidents quickly and expertly.
The Board of Inquiry Methodology.
The current Board of Inquiry approach resulted from the Defence Inquiry into the Effectiveness of Australia's Military Justice System of 2005, which was prompted largely by a number of high-profile personnel management problems. The death of any ADF person now needs to be investigated by an independent and legally constituted Board of Inquiry, a generalisation that does not recognise the peculiar operational and technical complexities that must be resolved before the root cause of any military accident, and hence the means of preventing recurrences, can be determined.
For the Sea King inquiry, there was a preponderance of legal people over operational and technical expertise. With 13 potentially affected persons, all legally represented, the inquiry had 16 barristers all arguing legalities, rather than hard operational/technical evidence, possibly to justify their high fees. The inquiry could hardly become other than the usual legalistic squabble, totally dominating a board led, not inappropriately, by a legally-unversed Navy officer.
The Board of Inquiry's, legal-centric approach as mandated by Defence will never get to the facts or the root cause of any ADF accident, fatal or otherwise. The result will be a highly skewed, confused, and contrived result that will certainly not address real airworthiness or other important Military concerns.
The Measurement of Flight Safety Standards.
Towards the end of the Sea King Board of Inquiry, Defence released an overview of the ADF’s Airworthiness Management System which included a chart showing a marked reduction in ADF Aviation Fatal Accidents from 1970 to 2006, especially following the introduction of Technical and Operational Regulation.
However, fatal accident statistics are hardly a comforting measure of the technical (or operational) standards being maintained within the three Services. Fatal accident statistics only serve to remind us that we were too late, that all our safeguards, both technical and operational, have been breached. When looking at how airworthy ADF aircraft are, it is necessary to drop down a level and look at those incidents that had the potential to be fatal accidents, but escaped through good luck, but good luck must never be mistaken for or be represented as good management.
Unfortunately, these ‘near misses’ are not usually open to public scrutiny but sufficient have arisen lately to give cause for concern that the de-skilling and down-sizing of the Services, particularly the disbandment of Air Force and Navy Engineering branches, have impacted adversely on technical management, and hence technical airworthiness standards. For example:
The F-111 Incident of 2006.
At about 2-10pm, on 18th July 2006, an F-111 made a wheels-up emergency landing at RAAF Amberley following the loss of one of its main landing wheels on take-off. Fortunately, the loss of its port main wheel was noticed by the Control Tower and the pilot notified. The aircraft was also ‘clean’ (no external stores), and had several hours of fuel which allowed an unrushed emergency landing plan to be put in place. Congratulations all round followed the successful wheels-up landing.
Apparently, the problem arose from a 12cm long pin being installederted incorrectly in the main wheel assembly-a maintenance error seemingly affecting about half the F-111 fleet (10 or more aircraft).
However, the circumstances of the emergency could easily have been much more hazardous and so may well have graduated to the Fatal Accidents Chart, for example:
Sea King Incident 1, 2005.
During the sitting of the Board of Inquiry into the Sea King Tragedy that claimed nine lives and injured two at Nias Island on 2nd April 2005, evidence came forward of similar maintenance errors with a Sea King at Darwin on 3rd and 4th October 2005, some eighteen months later.
Despite the considerable attention given to Navy maintenance, training and documentation standards as a result of the Nias Island accident, a series of maintenance, supervision, and technical documentation errors resulted in the split pins in the tail pylon hinge bolts of a Sea King being removed and not replaced, giving rise to a flight safety hazard. Their absence was not detected by the maintenance technicians, the pilot who conducted his pre-flight inspection before the ground run, the technician who performed the next (turn-around) inspection, or the pilot who conducted the pre-flight inspection.
“The aircraft captain for the maintenance test pilot walked to the aircraft and conducted his pre-flight inspection. He had noticed that there was – the aircrew had been looking at the tarpaulin hinge, the tarpaulin latch, which is on the starboard side of the aircraft. While moving down to see what those aircrew had been looking at he noticed that the split pins were in fact missing from the bolts and castellated nuts on the tarpaulin hinge attachment bolts on the starboard side.”(Transcript, page 4719 ).
The episode was managed as an incident on the basis that the defences in fact worked, albeit it was the very last defence. (Transcript, page 4719).
However, just how close was this ‘incident’ to being a tragedy transcending even the Nias Island crash? In response to a question as to how serious the incident really was, the Responsible Engineering Officer (REO) stated:
“---Not to trivialize the accident (the Nias Id accident), but I see that (the Darwin incident) as worse than the accident, and I described that to them, to my people up there because, of all the human factors training, and all the maintenance stand downs and everything else that has happened since the (Nias) accident, it should never have happened up in Darwin. So, clearly, where we were going with our education process and our maintenance standards and practices some of it is being missed by some people, and that concerned me greatly, because that day there were going to be three aircrew and 10 maintainers were getting in that aircraft for that Flight because they were flying from RAAF Darwin to Robertson Barracks, and it really hit home to the maintainers that (they) were getting in that aircraft when it was picked up , but it shouldn’t have taken that, to do it. And I’ll tell you now that – and I then went and spoke to the aircrew an hour after that to stand in front of two full crews because we were launching a second aircraft at the same time , and to try to explain to two of the pilots that were there flying the other aircraft at Nias, that I still have confidence in flying in the aircraft, I was at a loss to describe it. And, to be honest, I was ready to chuck it in and go home, because if the education process had been put in place so far hasn’t worked, I clearly don’t know what we can do”. (Transcript, page 4194).
The impacts upon both aircrew and ground crew of these continuing maintenance errors are covered well in the transcripts of evidence.
The President of the Board was certainly aware of the Board’s objectives, for example when he questioned WOff Chinello over the Darwin ‘incident’:
“-----The fact that we’re still getting people doing walk-arounds and implementing bad practices I guess is a an example or I guess demonstrates the fact we’re just nibbling around the edges. All those measures that I have seen so far to me appear to be soft measures, which is why I ask: What have you put in place to try to stop this from happening again rather than just briefing and some education down the track? It is important to us because that’s what we are meant to do as a Board and that’s why I am asking the question: What hard measures do you think you can put in place? Because ultimately the Board has to make recommendations about hard measures?” (Transcript, pages 4735 and 4736).
Only further nibbling followed because the WOff had done all that he could and had no coherent technical management organization to support him, just disparate groups scattered throughout the organization. However, the WOff had hit the mark in passing when he said:
“-----I don’t believe that there is any process that you could really put in place here that is going to prevent this action short of completely reorganizing the way we do management within naval aviation. I think we still need to have faith in our maintenance staff, because nearly every single maintainer I’ve met has acted in good faith. Indeed, the two Leading Seamen here have acted in good faith, albeit they’ve committed what is essential a pretty nasty violation“. (Transcript, page 4735).
The WOff was correct – good people trying to do their best within a dysfunctional, non-technical, management organization.
Sea King Incident 2, 2007.
On 18th May 2007, all six Sea Kings were again grounded over safety concerns when two split pins were found to be missing during a pre- flight inspection. Although Navy stated that the missing pins were “not critical to flight safety”, it was another serious maintenance error, and good luck seems to be again the saviour rather than good management.
Black Hawk Incidents 1, 2, and 3.
Given that an aircraft is technically safe to fly, it must be flown safely if accidents are to be avoided. In looking at airmanship standards within the ADF, the Black Hawk Board of Inquiry provides a warning as to what will inevitably happen when:
“Finally then, in some sort of summary, you have this audit system in place and 171 Squadron was the subject of audit a number of times recently. But also recently, in the past six months, we’ve had three significant aircraft incidents – 29 November when the aircraft was lost; there was an incident of ASOR 002, where an aircraft struck a building while doing a special operations approach; and, finally, there was an incident just recently in East Timor where we had a Cat 4 accident. All of these incidents were Black Hawks conducting special operations approaches and downwind. Do we need to improve the audit process?” (Transcript, pages 1771 and 1772).
Clearly, neither Navy nor Army was organizationally capable of responding to the need for urgent corrective action, thereby allowing the potential for further fatal accidents to persist. Fortunately, good luck again replaced good management and only major aircraft damage resulted.
In summary, it is not adequate that ADF flight safety standards be measured by its fatal accident statistics. The ‘near misses’ given as examples provide a more realistic measure and, more importantly, carry a much better chance of identifying the root cause of the problem –the inappropriate organizations forced upon the Services, particularly the disbandment of their engineering branches which has resulted in an unacceptable loss of technology management skills and experience.
What to do?
If the central question of the proper management of technology in each of the Services is not faced and resolved, then Murphy will not be restrained and, as a result, we simply await the next accident and the next fatality.
Finally, with Defence now looking at laying serious charges in regard to the Sea King Tragedy against those considered to warrant such action, it is important that such action be directed at those who imposed the current dysfunctional organisation upon the Services rather than those who have tried to do their best within that organisation.
The Language Barrier
The RAAF, since its formation, developed a very high level of administrative competence based on high quality staff work. The reason was simple - messages, written or verbal, had to be clear, concise, and complete if mistakes, and their usually inevitable consequences, were to be avoided. It was often a case of life or death, a very mind focussing concept. The importance of clear and well-reasoned argument and unambiguous written expression were emphasised at every level of the RAAF and were organic to all promotion examinations and courses. From reading current Service staff work, and especially that emanating from Defence in Canberra, it is clear that the high standards that existed prior to Sanderson and the DRP have not survived. Largely, they have been replaced by the jargon of the bureaucracy where the objectives of communication are far too often quite opposite to those of the Services.
Today, truth and precision in language have succumbed to vague, often incomprehensible waffle that uses meaningless terms created by the 'nouveau management philosophy movement'. Even the author cannot understand it, let alone the recipient. What should take but half a page now takes several pages of rambling clichés, the message buried beyond recovery. In almost every case, the basic principles underlying effective management are ignored, replaced if at all by strange references to 'good governance', a term seemingly introduced to replace sound management, which is no longer understood.
The importance of high quality staff work cannot be overestimated. If Defence and the Services are to improve anything, all should start with the principles of management and the importance of clear and concise English expression. Should an example of current failures be needed, then it is only a matter of reading the Charter for the Chief of Air Force, at Attachment 2. There can be little wonder why management is in such a muddled state from the top down.
Those who wish to see how responsibilities should be expressed should refer to the Minister's delegations to the Service Board members, pre-Tange.
administration of the RAAF, was based upon a filing system that
identified Service policy and recorded the management of each
activity arising from that policy, Files were kept for an indefinite
period, providing a chronological history that was referred to often
as a tool of management. It produced, in effect, an audit trail. The
imposition of the Public Service filing system is totally inimical to
Military requirements and should be discarded throughout the Services
and the Department of Defence. It appears to avoid recording policy,
records no useful history, and ensures that there is no audit trail.
Its management objectives are thus quite questionable.
RAAF Iroquois helicopters (US DoD Image).
THE VIETNAM WAR AND THE IROQUOIS SAGA
Operating at extremely high Rates Of Effort (ROE), the RAAF's achievements in the seven years of the Vietnam conflict were an amazing tribute to the pilot/maintenance team. The mission achievements by three different aircraft types, Canberras of No 2 Sqn at Phan-Rang (April 1967), Caribous of No 35 Sqn at Vung Tau (July 1964), and Iroquois of No. 9 Sqn at Vung Tau / Phuoc Tuy Province (June 1966), were not attributed solely to the skill and application of aircrews, but also to the dedicated expertise of the maintenance personnel who were working under extremely primitive and arduous conditions. The American services were to pay several visits to RAAF units to determine how such high serviceability rates could be maintained together with high operational utilisation and low losses. The 'secret' was essentially the span and depth of training, and the initiative characteristic of RAAF technical staff since the formation of the Service.
Invariably, the aircraft would incur battle damage, but the pilot would recover to safe areas. Battle damage repairs often required innovative engineering. Many times the maintenance technician was called upon to develop field repair processes, many of which were beyond the comprehension of the aircraft designer, but it would be true to say that the skill was in many cases supplemented by common sense and a fair degree of good fortune. This combination enabled the RAAF to emerge from Vietnam with comparatively low aircraft losses in relation to the number of operational missions flown.
During the seven year period of the conflict up until November 1971, the RAAF’s aircraft losses totalled 12 from the three squadrons based at Phan Rang and Vung Tau. A further 17 aircraft incurred major battle damage and there were 78 incidents of minor damage. The latter were mostly attributed to small arms ground fire.
However, during the late 1960s, the sustained demands of Vietnam and the higher ROE demanded from the local pilot training units were starting to take toll on the performance standards being achieved by the RAAF Iroquois fleet. Stark evidence was seen in the difference in performance between No 5 and No 9 Squadrons, the former operating out of RAAF Base Fairbairn in the ACT and the latter out of Vietnam. It was not surprising to find attention being focused on the maintenance standards and procedures at No 5 Squadron.
A fatal accident involving A2-710 led to Headquarters Operational Command, (Senior Technical Staff Officer, Gp Capt Jim Rowland, later to become Air Marshal Sir James) initiating a major study of No 5 Squadron maintenance practices. The HQOC Working Group involved considerable engineering and helicopter maintenance expertise in the form of Sqn Ldrs Ray Meredith and Jim Beer, Major Joe Davis (USAF), and Wg Cdr 'Bowser' Bill Greenham.
High ROE and the dilution of technical skills caused by the high manpower turn-over rates needed to support 9 Squadron Vietnam operations were found to be reflecting adversely on No 5 Squadron’s Planned Flying Maintenance. The HQOC group concluded that the task of retrieving the flying-maintenance stagger would require some four months of dedicated effort, but before this could be achieved No 5 Squadron was to experience a second fatal accident.
The loss of A2-386 at Canberra on 2nd April 1969 through separation of the semi-rigid main rotor led to the grounding of the 5 Squadron Iroquois fleet and raised serious concern as to the airworthiness of the whole RAAF Iroquois fleet. The Air member for Technical Services, Air Vice Marshal Ernie Hey, reacted in an unprecedented way. He convened a Technical Investigation Committee to examine the engineering integrity of the Iroquois fleet. Working separately, but in harmony with the Director of Flying Safety’s Court of Inquiry, the Technical Committee was to examine all facets of Iroquois engineering standards, operating, and maintenance practices.
As the Iroquois aircraft was operating world wide without problem, the basic design was not considered to be in question. Again, attention was to focus sharply on maintenance. To establish a base-line for the study, the Committee undertook a special inspection of A2-1025, a veteran of Vietnam. This inspection was supervised directly by senior engineer officers from the then Department of Air and Headquarters Support Command.
During the special inspection, close attention was given to the non-destructive inspection of the transmission and rotor assemblies. Maintenance practices of both the highly sensitive hydraulic and transmission systems also came under particular scrutiny. Other critical review areas included technical documentation. These were seen as vital elements in configuration management and engineering standards forming the airworthiness chain.
After some weeks of close association with No 5 Squadron’s operating level maintenance, the Committee concluded that the autorotation landing practice techniques being used were contributing to long-term aircraft structural damage and needed to be changed. Perhaps of greater significance was the clear relationship between high and sustained ROE, spares supply, maintenance resources, and the dilution of technical skills and maintenance standards. The problems were best expressed by Gp Capt Roy Ayre in the Committee’s report to AMTS. The valedictory read:
“Make do and thin butter
Put Squadrons in the gutter
Badly blunts sharp end
Costs more in the end.”
The initial findings of the Technical Committee were to lead to a major rehabilitation programme involving the entire 5 Squadron fleet. AMTS saw it as being necessary to re-assume responsibility for the programme which was implemented on the 5th May 1969 under the control of Sqn Ldr Ron Tucker. The programme extended over 16 weeks and was concluded on 25th August 1969. During this time, three maintenance teams made up of 19 personnel drawn from the various technical trades provided a concentrated maintenance effort. In the 16 week period, they provided some 3,851 manhours of overtime, of which 1,240 manhours were achieved during the first four weeks. The teams processed 26 aircraft and undertook one 'E', 10 'D', and 14 'C' servicings.
The Committee had demonstrated a basic lesson in engineering resource management that is equally as valid today, that is that any force expansion involving high and sustained ROE with resource limitations will inevitably produce the same results as the Iroquois experience of 1969. Today’s defence planners and resource managers could well benefit from the Committee’s lesson, as well as the demonstrated effectiveness of the RAAF's Technical Services Branch .
CHARTER OF THE CHIEF OF AIR FORCE
Air Marshal Geoffrey Shepherd, AO
Chief of Air Force
3. In the event of the CDF’s temporary absence, you will be accountable for carrying out any of his responsibilities that are delegated or authorised to you in writing, or otherwise.
5. We expect you to set the standard in everything you do, and to:
a. deliver Air Force capability for the defence of Australia and its interests, including the delivery of aerospace capability, enhancing the Air Force’s reputation and positioning the Air Force for the future;
b. raise, train and sustain Air Force forces by proper stewardship of people and of financial and other resources, in particular through:
i. developing leadership and behaviours that advance and embed the Results through People leadership philosophy,
ii. developing and maintaining Air Force workforce skills, career structures and promotions up to and including Group Captain,
iii. building and maintaining the reputations of the Air Force and Defence as a whole, and
iv. achieving or bettering budgeted operating results;
c. coordinate and manage strategic aspects of Australian Defence Force aviation;
d. act as the Australian Defence Force airworthiness authority;
e. provide timely, accurate and considered advice, in particular:
i. via input to intelligence and policy advice that enables the Government to assess its strategic direction continuously,
ii. on Air Force and military capabilities for the force in being and the future force, and
iii. through your membership of the Defence Committee, the Chiefs of Service Committee, the Defence Capability and Investment Committee and other committees in support of whole-of-Defence results;
f. contribute to Defence and Government security by supporting strategies to raise security awareness, establish a strong security culture and improve security management.
6. You should pursue these results through effective leadership and management; and should ensure that:
a. your actions are prudent, lawful and ethical;
b. your actions are consistent with:
i. Government policy, including Government-approved options for current and future capabilities,
ii. Air Force, APS and Defence values,
iii. the CDF’s authority as commander of the Defence Force under the Defence Act 1903, his statutory responsibilities and his role as principal military adviser,
iv. the Air Force Act 1923,
v. the Secretary’s statutory responsibilities and authority, particularly under the Public Service Act 1999 and the Financial Management and Accountability Act 1997, and his role as principal civilian adviser, and
vi. Defence departmental frameworks, policies and standards;
c. your decisions and advice consider the impact on others, (including the leadership of foreign forces), and you:
i. consult and collaborate as appropriate,
ii. properly manage risk,
iii. meet explicit and implicit mutual obligations to other Service Chiefs, Group Heads, Australian Defence Headquarters (ADHQ) Executives and the CEO DMO, including supporting Defence Committee decisions, and
iv. inform the Secretary and CDF (and other Defence Committee members as appropriate) of advice you offer to the Ministers and the Parliamentary Secretary; and
d. your decisions and advice take into account the impact on sustainable delivery of Defence’s outputs.
ACM A.G. HOUSTON R.C. SMITH
Chief of the Defence Force Secretary
13 September 2006 13 September 2006
 Murphy's Law - "Whatever can go wrong, will go wrong". For a detailed discussion of the origins of Murphy's Law, refer Murphy's Law; a formal engineering statement of Murphy's Law amounts to 'unconstrained degrees of freedom in a system can and will result in unwanted consequences'. In reliability engineering terms Murphy's Law is a manifestation of Lusser's Product Law which states that 'the probability of survival in a serial system is the product of the probabilities of survival of all critical system components'. For a formal mathematical treatment refer Igor Bazovsky - Reliability Theory And Practice, Dover Publications, 10/2004, ISBN-13: 9780486438672.
 Editor's note - the RAAF's experience with the Iroquois parallels the long running historical experience of many air forces, especially under combat conditions where materiel resources and technical personnel numbers were stretched. A well documented case study is the US Army Air Corps 8th Air Force in 1943, operating from the United Kingdom. Significant losses in aircraft and aircrew, especially scarce escort fighters and qualified pilots, were suffered until the proper organisational structures and practices were introduced, and properly skilled personnel made available. In the contemporary RAAF context, a good case study lies in the servicability of the F-111 fleet prior to the 2002 transition from organic depot level deep maintenance, to contractor supplied deep maintenance. The large disparity in technical personnel skills and experience between RAAF personnel, and the contractor personnel (mostly former RAAF personnel) resulted in an unprecedented improvement in aircraft availability and reliability, to levels better than 1974, after many years of poor servicability. The lesson here is not that 'contractor maintenance is better than service maintenance', but rather that 'maintenance by skilled personnel with proper supporting engineering and engineering management is better than maintenance without such'. In the longer term, increasingly complex technology and the increasing need to support complex embedded software will drive up demands for engineering and technical personnel skills. Issues raised by Air Commodore Bushell in this analysis, such as configuration control, become literally 'life and death' issues from an airworthiness perspective. An aircraft with millions of lines of embedded software in its systems, and tens of thousands of hardware components, cannot be maintained in an airworthy, let alone combat effective, state without a very robust supporting engineering capability - one which has no conflicts of interest such as those seen with many contractors providing maintenance.
RAAF F-111C aircraft (US DoD Image).
Air Power Australia Analyses ISSN 1832-2433
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