Reading the report was a stunning experience and a lesson in a classic case of a company allowing standards to slip and slide down the slippery slope which leads inevitably to a smoking hole.
The most significant point is that the company Quality and Safety policy failed to audit and then ensure that corrective actions were taken to rectify an obvious culture of overlooking problems and illegally deferring faults. The Lightning aircraft have had a poor safety record, but at the end of the day it is the human failings which led to the loss of life and the aircraft. That could have been avoided with proper adherance to quality and safety.
On the Vulcan we have an internal TVOC Quality Audit system, with both planned formal audits of M5 procedures and random spot check audits, which I spring on the engineers usually without warning. Recommendations have to be met by response to Corrective Action Requests(CAR) and are automatically monitored by a computorised management system to ensure they are met in a reasonable time scale.
In addition when we are audited by the CAA, we raise their audit findings and any CAR raised against us into our system so that the relevant responsible TVOC department head is automatically informed and required to reply to our QA Supervisor, who then responds to the CAA to close the loop. In addition we have shop floor level Safety Action Group meetings and also Safety Review Committee meetings chaired by an independent aviation safety expert throughout the year which report back to the VTST.
We are not permitted to fly with defects and any deferred maintenance has to be authorised by the CAA BCAR E4 Engineering Authority Organisation.
When these sort of processes are not done and properly followed up, as it seems they were not in the case of the Lightning, then the scene is set almost inevitably for disaster.
