RAFManualofFlightSafety

AP3207
Edition8

AP 3207
RAF MANUAL OF FLIGHT SAFETY
8th Edition
BY COMMAND OF DCom Ops

ROYAL AIR FORCE

CONDITIONS OF RELEASE
1. This information is Crown copyright and the intellectual property
rights for this publication belong exclusively to the Ministry of
Defence (MOD). No material or information contained in this
publication should be reproduced, stored in a retrieval system or
transmitted in any form outside MOD establishments except as
authorised by the sponsor and the MOD where appropriate.
2. This information is released by the United Kingdom Government
to a recipient Government for defence purposes only. It may be
disclosed only within the Defence Department of a recipient
Government, except as otherwise authorized by MOD.
3. This information may be subject to privately owned rights.

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RAF Air Command

Management Authority

RAF Flight Safety

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RAF MANUAL OF FLIGHT SAFETY
8th Edition

Preface
AP3207 has been re-introduced by the Royal Air Force as the RAF Manual of Flight
Safety. The 7th Edition was superseded in July 2003 by the JSP 55X series of
documents regulating Military Aviation. With the establishment of the Military Aviation
Authority (MAA) in 2010, the RAF identified a need for a comprehensive Aviation
Safety Management Plan, which required a reintroduction of AP3207 via an 8th
Edition. These documents are jointly intended to compliment MAA policy and
regulatory instruction and are undergoing a phased introduction to ensure a fullyassured RAF Air Safety Programme. This Programme fully integrates traditional
Flight Safety policy with that of ATC/ABM and Airworthiness.

AP3207 Index Link

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RAF MANUAL OF FLIGHT SAFETY

FLIGHT SAFETY AIM, POLICY AND PRINCIPLES
FOREWORD
1.
Authority. The authority to operate and regulate UK Military Aircraft is vested in the
Secretary of State for Defence. The authority to operate aircraft is delegated to the service
Chiefs of Staff and the Chief of Defence Material, who in turn delegate that authority to
Aircraft Operating Authorities for aircraft and air systems for which they are responsible.
The authority to regulate is delegated to the 2nd Permanent Under-Secretary (2nd PUS), as
Chairman of the Defence Environment and Safety Board, who in turn delegates to the
Director General, Military Aviation Authority (MAA). With the exception of Queens
Regulations, MAA documents have primacy over all military aviation related documents.
Pursuant to his delegation of authority to operate aircraft and air systems of the Royal Air
Force, the Chief of the Air Staff, directs that the regulations and policies contained within
are to be complied with as a minimum standard, unless more stringent criteria are imposed
by subordinate documents apply or they come into conflict with those of higher authority.
2.
Aviation occurrences in the RAF constitute a considerable drain on operational
capability, lives and aircraft vital resources upon which the Nation depends for its
security. The cost of training personnel and the acquisition of modern aircraft make the
preservation of these resources a major consideration in the efficient accomplishment of
the RAF task. However, military flying necessarily includes an element of risk and a
balance has to be reached between air safety considerations, of which flight safety is an
integral constituent, and acceptance of those risks which are essential to completion of the
task. The decision on the right balance, or risk threshold, is largely one for subjective
judgement by Duty Holders and it should aim at ensuring optimum prospects of successful
task achievement with both a tolerable and as low as reasonably practicable risk to aircraft
and personnel. By contributing to task success in this way, flight safety makes a major
contribution to air safety and the operational efficiency of the RAF.
AIM
3.
The aim of flight safety is to increase the operational efficiency of the RAF by
reducing to both tolerable as low as reasonably practicable those risks to life, operations
and equipment which contribute to aircraft accidents. It is a universal principle which
applies equally to the Four Worlds of operations, engineering, ABM and direct support to
operations.
FLIGHT SAFETY POLICY
4.
Flight safety policy within the RAF is overridingly characterised by the need to avoid
the very high cost of losses and damage involved in aircraft accidents. However, accident
avoidance cannot be accomplished in isolation; the Duty Holder and commanders task
includes an assessment of the balance of priorities. In war, task achievement is
paramount and a high degree of risk may have to be accepted if operational requirements
so dictate. In peace, avoidance of unnecessarily high levels of risk is generally paramount
within stated training or operational task requirements. Thus the Duty Holder must
constantly adjust the risk threshold to take account of the flight safety and operational
factors involved whilst fostering a Just Culture while simultaneously maintaining liability for
the risks he accepts. Risk identification is crucial to this decision-making process.
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Hazards, both real and potential, create risk and can be identified and regulated at all
command level or in any phase of flying operations and it behoves all personnel,
regardless of status or responsibility, to be aware of the need to identify, avoid and
eliminate unnecessary risks wherever possible. Thus, flight safety is all-pervasive with
each individual having a part to play in developing awareness towards it.
5.
The executive responsibilities of Duty Holder concept dictate that flight safety and
over-arching air safety rest within the chain of command, from the most junior ranks
upwards. The task of established flight safety staffs is to provide specialist advice and
guidance which will assist the Duty Holder to meet this responsibility with maximum
effectiveness. However, the importance of this advisory role is reflected in the direct
access to the Commander In Chief, Air Command, and the Chief of the Air Staff, which is
afforded to the Inspector of Flight Safety. Thus, in effect, flight safety needs are given
equal precedence to airworthiness but the responsibility for any compromise between
them falls on the respective Duty Holder.
FLIGHT SAFETY PRINCIPLES
6.
Successful implementation of flight safety policy is dependent upon the application of
working principles which have evolved with the increasing complexity of flying operations.
These principles are outlined in the following paragraphs.
7.
Responsibility. The flight safety organisation in itself has no executive function and
holds no duty or risk as an individual entity; its role is to train, monitor and provide
assurance to its respective Duty Holder. Executive responsibility for implementation of
flight safety measures lies with the Duty Holder himself in the light of his perceived balance
of safety and operational considerations; assessment of acceptable risk thresholds is
crucial to this process.
8.
Precedence. In the assessment of risk thresholds, flight safety generally should
enjoy at least equal precedence to airworthiness and operational considerations, which in
combination provide Air Safety. Even in war, flight safety considerations will be important if
both human and material resources are to be preserved.
9.
Organisation. An appropriate and fully-manned flight safety organisation should be
structured alongside an airworthiness organisation so that it can communicate directly with
the Duty Holder and his executives at all levels. Each level must be both auditable by and
accountable to the superior Duty Holders flight safety organisation and, ultimately, the
MAA and 2 PUS. In this way, flying activities will be considered in the context of flight
safety at all levels of command.
10. Risk Awareness. Although executive authority for flight safety measures rests with
the Duty Holder, it is incumbent upon all personnel, both Service and civilian, to play their
own part in accident prevention. Risk detection and avoidance is crucial to this process;
even risks or instances of carelessness which are trivial in themselves can, in isolation or
in combination with other factors, cause an accident to occur. This flight safety awareness
must be maintained meticulously by all those associated with aircraft operations, however
remotely. As a corollary, flight safety staffs should take active steps to promote and sustain
adequate levels of risk awareness within their sphere of responsibility.
11. Potential Root Causes. Whereas risk awareness can help to avoid accidents and
incidents during day-to-day aircraft operations, it is incumbent upon the individual, and
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flight safety staffs in particular, to seek to identify potential root causes wherever possible.
This is especially important when changes are made (eg in aircraft types, and techniques)
but many potential root causes may be present which are not new in themselves, eg
insufficient anticipation of climatic or seasonal changes, failure to detect a general lowering
of operating standards and competencies. Flight safety surveys, review of standardisation
and evaluation findings, studies of flight safety occurrence reports and analysis of
collected data can help in this detection process and mock accidents and investigations
can also play a part. Nevertheless these cannot replace the need for everyone to be
constantly air-minded and flight safety aware in the identification of potential causes of
accidents.
12. Reporting System. Full, open, timely and accurate reporting of aviation occurrences
is essential to the maintenance of good flying safety. Accurate reports, including details of
resulting investigations, allow important lessons to be learned and so play a major part in
future accident prevention. Furthermore, the reports provide the basis for remedial action,
statistical analysis and publicity all important principles of flight safety in themselves.
Much of the responsibility for accurate reporting rests within an air safety element at
individual stations, which can also take remedial action if necessary. However, the reports
must be passed to both higher and associated formations in order that the overall picture
can be analysed for wider application of remedial measures where required. The reports
should not be used as a medium for executive administrative action but, where such
proposals stem logically from the investigation, which may occur through the Aviation
Safety Information Management System (ASIMS), the report should include details of the
remedial or preventive action that has been initiated through the appropriate specialist
channels. Similarly, ASIMS should not be a substitute for specialist RAF reports for
occurrences such as MT accidents, armament accidents, casualty procedure etc, although
it is both mandatory and complementary to submit such ASIMS reports when aircraft or air
operations are involved.
13. Investigation Procedures. All accidents and incidents require thorough
investigation to determine remedial action and to highlight lessons learned. Incidents of a
routine nature generally should be investigated by unit or station personnel who should
use the ASIMS reporting system to forward details to higher authority. Occurrences
requiring more in-depth investigation should initially be reported in ASIMS and be
formalised and reported via a unit-level (ie: RAF Error Decision Aide (RAFEDA), DAEMS,
F765(B)-to be superseded) investigation. Accidents, together with occurrences of a more
serious nature, should be the subject of a formal Unit Inquiry convened at station level or a
Service Inquiry which will be convened by the MAA. Where the cause of an accident is
obscure, the MAA may invite the Air Accidents Investigation Branch (AAIB) of the
Department of Transport or similar professional entities to assist its own MAAIB in the
conduct of the Service investigation. In each instance, the personnel of the RAF are to
provide full assistance to the investigating authority and his agents. Whatever the form or
level of investigation, however, it must be thorough; often this can place a great
responsibility on the flight safety organisation at all Duty Holder levels. In any
investigation, it is not sufficient just to know what happened; all possible causes must be
discussed so that appropriate remedial action can be taken-this is to include all elements
of airworthiness and error management. Above all, the causes must not be confused with,
or obscured by, the ultimate effect.
14. Remedial Action. Executive branches are responsible for remedial action
considered necessary as a result of flight safety investigations. Thus it is important that
flight safety staffs pass accident data and analysis to the executive branches and Duty
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Holders without delay; where necessary, corrective measures or remedial action may be
proposed for action. Those executives and duty holders tasked with remedial actions will
remain accountable to both Chief of the Air Staff, via RAF Flight Safety, and the MAA for
timely reporting of progress on and completion of these recommendations for remedial
action. In each instance, remedial action or rejection of recommendations must result in a
risk to life, operational capability and reputation that is both tolerable and as low as
reasonably practicable. Generally, the following considerations will apply:
a.
Time Factor. Generally speaking, remedial action should be taken as quickly as
possible so that further occurrences may be avoided. Even so, this may take some
time, especially when technical modifications have to be designed, produced and
incorporated.
b.
Cost Factor. The cost of remedial action must be taken into account. It would
be uneconomical to devise a modification which would cost more than the damage
sustained in the accident. For example, supposing an aircraft with a life of 10 years
was to develop an accident cause in its sixth year with a probable accident rate of
4 per year at a cost of 100,000 per accident. Remedial modification action is
suggested which would cost a total of 1,200,000. At first sight it would be
economical to modify but, if it would take 2 years to effect the modification, only 2
years life would be left and thus only 8 accidents avoided. Therefore remedial action
would not be economical and any recommendation to that effect is likely to be
refused unless some other overriding factor justified the expense (eg the possible
prevention of a fatality or injury, with loss of life being the central risk factor).
c.
Positive Action. All remedial action should be positive in its effect. For
example, if pilots were consistently overrunning because of too high an airspeed on
the approach, the remedy could be to lengthen the runway. It could also be attained
by training the pilots to use the correct landing speeds. One is negative and costly,
the other positive and economical. The most negative remedial action is to stop
flying. This leads to the most important aspect to be considered when contemplating
any remedial action operational necessity.
d.
Operational Necessity. In all remedial action, operational factors must be
considered first, which is the reason why executive branches and not the flight safety
organisation are responsible for implementing remedial action. Such action would be
justified if the resulting reduction in operational efficiency was less than that
generated by the accident potential.
e.
Chain of Command. Recommendations for specific remedial action should be
forwarded using the normal executive reporting chain. After considering the
proposals Commands should forward them to the appropriate MOD branch or
engineering authority; a copy shall be sent to IFS (RAF Flight Safety) to assure
progress of recommendations.
15. Accountability. The circulation of accident reports, both within and outside the
Service, allows the RAF to account for its major accidents to its personnel and to the
public, including Parliament and the Press. Such reports publicise the circumstances,
causes and follow-up actions taken. Internal reports offer advice to prevent recurrence of
the event and a wide circulation allows as many as possible to learn the relevant lessons.
In this way, accountability promotes flight safety.

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16. Study and Analysis. Study and analysis of recorded data is important if all lessons
learned, together with remedial action, are to be extracted from the flight safety reporting
system and Duty Holder assurance process. Occurrence reports and results of both
assurance and ensurance activity must be studied not only for their intrinsic value but also
in context of other, similar, reports so as to determine common features. Accidents or
incidents reported at unit level may appear as isolated occurrences whereas group HQ,
command HQ, IFS (RAF Flight Safety) or MAA, by comparing the incident with others
retrieved from occurrence records and other information, can take a broader view and
detect trends. Similarly, when operating circumstances change (eg by introducing new
aircraft types, techniques or roles), study and analysis of data can help to ensure that
causes of past accidents are not reintroduced. Appropriate analysis must occur at all Duty
Holder levels.
17. Training and Publicity. The flight safety organisation must not just gather
information, it must also disseminate it. This task can be divided into training and publicity.
a.
Training. While flight safety is an essential part of the task of everyone
concerned with flying, those selected for flight safety appointments need special
training. Section 300.115 give details of training courses and requirements for
specific individuals within duty holder organisations.
b.
Publicity. The information published by the flight safety organisation is based
on the principle of air and flight safety awareness; if everyone connected with the
Four Worlds of operating aircraft is told how, in his sphere, accidents can be, or have
been, caused, then the possibility of a repetition of such accidents is reduced. In
addition flight safety messages of a general nature (eg Dont Assume Check) can
help personnel to detect or avoid potential causes of accidents.
18. Exchange of Information. Other military, civil and commercial flying organisations
have similar accident problems and flight safety organisations; exchange of information
between them is thus mutually beneficial and desirable. This is better undertaken by the
flight safety organisation rather than by a number of executive branches, and channels
should be secured for an exchange of relevant information with similar organisations.
Within the MOD, the primary conduit of exchange is the MAA. Within the RAF, it is RAF
Flight Safety. In addition, there should be an exchange of information with the aircraft
industry for, as in the past, some firms have unwittingly repeated the mistakes of others.
Primary responsibility for exchange of information with industry will lie with the
Airworthiness Authority. Throughout such exchanges, due regard should be paid to
security considerations and diplomatic agreement.

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RAF MANUAL OF FLIGHT SAFETY

TABLE OF CONTENTS
Issuing Authority
Preface
Foreword
Table of Contents
Amendment Record
Request for Changes
SECTION 100 RAF AIR SAFETY MANAGEMENT PLAN
FS100.100
FS100.105

Introduction
RAF Air Safety Organisation Diagrams - To be Issued

SECTION 200 OCCURRENCE REPORTING AND INVESTIGATIONS

FS200.100
FS200.105
FS200.110
FS200.115
FS200.120
FS200.125
FS200.130
FS200.135
FS200.140
FS200.145
FS200.150
FS200.155
FS200.160
FS200.165

Flight Safety Records, Statistics and Analysis

Occurrence Reporting Procedures - Change 2
Types of Flight Safety Investigations - Change 2
RAF Service Inquiry Procedures
RAF Occurrence Safety Investigation - Change 2
Joint Investigations
Error Management
RAF Just Culture Policy
Flight Safety Procedures on Operations
Occurrences Involving Non-RAF Aircraft
RAF Post Crash Management - Change 1
RAF FOD Policy
RAF FDM Policy- To be issued
RAF Fatigue Management Policy

SECTION 300 RAF ASSURANCE, PUBLICITY AND EDUCATION

FS300.100
FS300.105
FS300.110
FS300.115
FS300.120
FS300.125

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Command Air Safety Assurance and Audit Procedures -To be issued

HF Policy- Change 1
Publicity and Awards
Training and Education To be issued
Station Flight Safety Officer Policy
Currency, Competency and Assurance of Standardisation Units

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AMENDMENT RECORD SHEET

Amendment No

Date of Change

Incorporated By

Date Incorporated

Initial Issue

N/A

RAF FS SO2 Policy

18 May 11

27 Jun 12

RAF FS SO2 Policy

13 July 12

12 Jan 13

RAF FS SO2 Policy

15 Jan 13

3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

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REQUEST FOR CHANGE (RFC) FORM
The primary method of suggesting change should be via e-mail to Air Flt Safety SO2 Policy.
Alternatively the form below can sent to: RAF Flight Safety, Lancaster Block, HQ Air Command,
RAF High Wycombe, Buckinghamshire, HP14 4UE
Originators Contact Details
Name:

Rank/Rate:

Date:

Post:

Contact Number(s):

Work
Address
and
Email:

Signature:

Details of Request For Change

Section / Chapter / Page /
Paragraph:
Requested Amendment:

Unit Approval
Name:

Rank:

Date:

Post:

Contact Number(s):

Work
Address:

Signature:

RFC Serial Number (RAF FS Use Only)

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100.100
AP7002 RAF SAFETY MANAGEMENT PLAN

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100.100 AP7002 RAF SAFETY MANAGEMENT PLAN (ASMP)

100.100.1 The RAF ASMP is designed to ensure that RAF personnel at all levels
understand the principles and workings of the RAF Aviation Management System (ASMS)
and applies to all RAF personnel together with those individuals, who are from equivalent
UK, foreign and civilian organisations who work within the RAF organisation. They are all
bound by its policy and should be made aware of its content.
100.100.2
The ASMP also provides high level guidance to senior leadership on the
principals of safety management and the importance of engendering an informed/engaged
safety culture. AP3207, the RAF Manual of Flight Safety, provides the direction and policy
to fulfil those principals.
100.100.3
All subsidiary RAF units, to include ODH, DDH, EAWs and other formed
units, to include those on deployed operations, will maintain their own ASMP to conform to
the RAF ASMP and MAA regulation.
100.100.4
As the RAF ASMP encompasses both the traditional Flight Safety and
Airworthiness objectives of Air Safety, it sits outside and above AP3207, with this Section
being reserved for policy and guidance specific to implementation and organisation of
ASMP activities. The RAF ASMP is available at this LINK (on MOD Intranet only).

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200.100
FLIGHT SAFETY RECORDS, STATISTICS AND
ANALYSIS

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200.100

FLIGHT SAFETY RECORDS AND STATISTICS

INTRODUCTION
200.100.1 It is essential that all occurrences, incidents and accidents are fully reported as
specified at Section 200.105 and the resulting information carefully analysed to ensure that
the lessons to be learned and the experience gained are fully utilised in improving flight
safety. A pre-requisite of this scheme is the maintenance of an adequate recording
system. For Defence, the ASIMS is the only method of documenting and cataloguing
these occurrences, regardless of the severity of their nature, and is the primary source of
data for flight safety analysis.
COMMAND, GROUP AND UNIT RECORDS
200.100.2 Because of the uneven level of flying activity between units and because
recording requirements will vary between levels of command and Duty Holders, a standard
system of recording is required to provide meaningful force-wide analysis. RAF Flight
Safety recognises that DDH and ODHs may elect to maintain specialist flight safety
recording systems for individual platforms in addition to ASIMS. When a specialist record
is created, its existence and location will be entered into the respective ASIMS report.
Such specialist records should be based on the general guidance given below and are
independently subject to audit by MAA, SDH and ODH assurance activity.
200.100.3 Accident Files. A file should be opened for each air or ground accident and
should be identified by aircraft type, mark, serial number and date of accident. The file
should contain copies of all papers relevant to the accident and its investigation. Such files
will contain the appropriate ASIMS D-ASOR cross-reference and relevant documentation
will be attached electronically to the final ASIMS D-ASOR after appropriate redaction by the
competent redaction authority.
200.100.4 Incident Files. Copies of the paperwork associated with each air or ground
incident should be kept either in bulk files covering a specific period or in individual files,
whichever is more convenient for processing and referring to specialists. Such files will
contain the appropriate ASIMS D-ASOR cross-reference and relevant documentation will
be attached electronically to the final ASIMS D-ASOR after appropriate redaction.
200.100.5 Accident/Incident Register. This register, which should include the basic
information listed at Annex A, can serve the dual purpose of recording the occurrence and
providing a guide to the administrative control and progression of all accident/incident
documentation. Larger formations may find it advantageous to divide the register, eg by
aircraft type, unit and type of occurrence.
200.100.6 Aircraft Accident/incident Record Cards. Command and group headquarters
may find it convenient to maintain a separate record card for each accident or incident in
addition to, or in place of, the accident/incident register. The record card should be
designed to simplify the extraction of data for reviews and studies, and will include the
appropriate ASIMS D-ASOR cross-reference.
200.100.7 Other Records. In addition to the foregoing, it may be useful to keep records
to meet the particular needs of a headquarters or station; eg running lists of specific
features such as abandonments, birdstrikes and radio failures.

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RAF FLIGHT SAFETY RECORDS

200.100.8
RAF Flight Safety Library. In addition to comprehensive data on RAF
accidents and incidents held on ASIMS and computer databases, RAF Flight Safety has
the ability to access an extensive library of historic flight safety material relating to
Commonwealth and certain foreign air forces and to UK civil aviation. The information
held by, or accessible to RAF Flight Safety is available, on request, to MOD branches,
flight safety staffs and panels of formal of inquiries. To avoid nugatory effort, it is important
that requests, which should be addressed to Inspector, RAF Flight Safety, are submitted in
writing and precisely worded, with parameters clearly stated. Requests by external private
entities must be submitted to the Business Secretariat, Air Command, RAF High
Wycombe, Bucks, HP14 4UE, as a formal Freedom of Information request.
STATISTICS
200.100.9
Accident/Incident Rates. In order to provide comparable
accident/incident information, the number of occurrences is related to the exposure to risk.
The normal measure of risk applied to military aviation is flying hours and the RAF uses
the military and civil aviation standard measures of incidents and/or accidents per 10,000
flying hours 1 . Thus, an accident rate of 0.2 per 10,000 flying hours indicates that, under
similar conditions, there would have been 2 accidents in 100,000 flying hours. However, in
the examination of occurrences relating to a particular phase of flight, some other measure
may be more appropriate, eg if landing accidents are being analysed, the number of
occurrences per 10,000 landings (and rollers) could be calculated.
200.100.10
Flying Effort Statistics. To calculate accident/incident rates, flight safety
officers must be in possession of up-to-date statistics of flying effort. At station level, the
SFSO should maintain a close liaison with the sections where these figures are compiled.
At headquarters, the ODH flight safety staff should obtain appropriate figures from the
force command or group statistics officer. Flying hour statistics are to be reported per
platform by the ODHs on a monthly and annual basis to the assurance arm of RAF Flight
Safety. See Annex B for format. These statistics are to show hours flown
monthly/annually per platform, clearly identifying which portion of the flying effort was flown
on operations. Such monthly and annual flying effort statistics are to be provided to the
Inspector, RAF Flight Safety, no later than 15 days from the close of the relevant period.
200.100.11
Security Classification of Statistics. Accident and incident statistics, or
certain combinations of statistical information, may reveal the RAF operational capability.
Until such time as they are presented to Parliament, or otherwise officially released to the
public, statistics from which flying effort may be deduced are to bear the appropriate
security classification.
200.100.12
Interpretation of Statistics. Flight safety data is subject to chance
fluctuations and it is essential that important decisions are not based on limited, and
possibly unreliable, information. The advice of RAF Flight Safety or the ODH flight safety
statistics specialist should always be sought if there is cause for doubt.
1

Accidents are those incidents which result in Category 4 or 5 aircraft damage OR where a person receives a fatal or major injury.
Where an incident involves both Cat 4/5 damage to a single aircraft AND/OR a fatal/major injury, it will count as a single accident for
statistical reporting. In cases where a single or multiple airframes are determined as Cat 4 or 5 damage, the accident number will
equal the number of Cat 4/5 aircraft, not the number of individuals with major or fatal injuries. Examples: (a) A single airframe Cat 4
rotary accident also involves the death of 3 persons in the air and on the ground, it is a single accident . (b) Where two airframes are
involved in an incident and neither is rated above Cat 3 damage, but a person receives a major or fatal injury, it will count as a single
accident.

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200.100.13
Submission of Statistics. DDH and ODH are to submit Financial Year
quarterly and annual analysis of occurrence reports to RAF Flight Safety for further review.
Such reports will compare occurrence rates to the previous quarter and the same period in
the previous year. This analysis will:
a. Examine both the platform and station period reporting rates.
b. Identify significant deviations between the periods and providing probable
causes, avoiding speculation without substantiation.
c. Examine causal groups (ie: technical failure, Human Factors (Aircrew)) of
occurrences at both platform and station level.
d. Examine system faults by major systems on each platform, identifying
significant deviations between periods and identifying/providing probable
causes.
200.100.14
RAF Flight Safety Quarterly and Annual Reports. Inspector, RAF Flight
Safety, shall provide quarterly and annual reports to Chief of the Air Staff via CinC Air
Command providing a summary and analysis of the previous periods activity, occurrence
reporting, error management, accident rate and areas of increased risk to individual life,
operational capability and reputation. See Annex C for format.
200.100.15
ODH Reporting of Assurance Activity. Respective ODH Safety Cells
shall report their assurance activities to RAF Flight Safety for inclusion in the Air Command
Yellow, Green and Blue Books or their successor documents. This assurance activity
specifically follows ODH action regards Service Inquiry Recommendations, Unit-Level
Investigations and RAF Station Assurance and Audit Activity. These updates will be due
no later than the last working day of the respective quarter. Failure to provide updates to
this deadline will result in a red entry in the book and flagging up to the CinC. Earlier
updates will be accepted throughout the quarter.
Annexes:
A.
B.
C.

Accident/Incident Register
Flying Effort Report
ODH Quarterly/Annual Analysis Report

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ANNEX A TO
AP 3207 Section
200.100
ACCIDENT/INCIDENT REGISTER
(See FS200.100.5)
Note: These suggested contents of a register should be adapted to meet the particular needs of
the user.
a.

ASIMS DFSOR Number:

b.

Squadron/Station/Group:

c.

Type of Accident or Incident, eg Birdstrike Accident:

d.

Aircraft Type, Mark and Number.

e.

Signal Messages Reference.

Date sent/received.

f.

Date Casualty Procedure complete.

g.

Bird Remains

h.

F765B/RAFEDA/DAEMS/Unit Inquiry Target date for dispatch.

Date to MAFF/GMGO (as applicable).

Date MAFF/GMGO (as applicable) report received.

Date dispatched/received.
j.

Service Inquiry Date convened.

Presidents Interim Report.
Date received from the MAA.
Date to/from Stn Cdr.
Date to/from AOC.
Date to/from CinC.
Date to IFS.

k.

F1669. Date dispatched/received.

i.

Brief details of accident/incident.

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ANNEX B TO
AP3207 Section
FLYING EFFORT SATISTICS AND TRACKING
Note: The suggested format for recording flying hours should be adapted to meet the specifc
needs of that platform. However, the minimum statistics that are expected follow.
1.

ODHs are to collate the following flying data to enable flight safety analysis at the their level:
a.

Achieved flying hours per platform/Sqn per month.

b.

Operational flying hours are to be recorded under Op name.

c.

All flying hours are to be recorded using the format [hh]:mm within excel.

2.

DDHs are to collate the following flying data and present to the ODH monthly:
a.

Units are to record Sqn flying hours per platform.

b.

Operational flying hours are to be recorded under Op name.

c.

All flying hours are to be recorded using the format [hh]:mm within excel.

3.
The DDH is required to present the following the data to the Inspector of RAF Flight Safety
no later than the 15th of each month:
a. Flying hours achieved per platform for the previous month.
b. All flying hours are to be presented using the format [hh]:mm within Excel.

NB: The requirement to compile this flying data is mandated from CinC and the Inspector of RAF
Flight Safety to enable quarterly Flight Safety analysis to be undertaken for the CAS.

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ANNEX C TO
AP3207 Section
SUBMISSION OF STATISTICS
Note: The format for producing analysis of occurrence reports to RAF Flight Safety is to be
produced from ASIMS.
1.

The example given below details the D-ASORs raised against Typhoon at RAF Coningsby
during the period 1 Jan 31 Mar 11. A comparison is given against the previous Qtr and
also the same Qtr in the previous year. In this case the causal groups have been used to
indicate the type of occurrence. Fig 1 3 refers.

3 Sqn

Coningsby - Typhoon DFSORs 1 Jan - 31 Mar 11

Incident

Under Investigation

29 Sqn

Technical Fault
Organis ational Fault

Incident

Not Pos itively Determ ined

Natural Operating Ris k

11 Sqn

Hum an Factors (Aircrew)

Incident

Fig 1.

3 Sqn

Coningsby - Typhoon DFSORs 1 Oct - 31 Dec 10

Incident

Uns atis factory Equipment

29 Sqn

Technical Fault
Not Pos itively Determ ined

Incident

Natural Operating Ris k

Human Factors (Maintenance)

11 Sqn

Human Factors (Aircrew)

Incident

Fig 2.

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Coningsby - Typhoon DFSORs 1 Jan - 31 Mar 10
Incident
3 Sqn

Unsatisfactory Equipment
Technical Fault

Incident
29 Sqn

Organisational Fault
Not Positively Determined

Incident
17 Sqn

Natural Operating Risk

Human Factors (Maintenance)

Incident
11 Sqn

Human Factors (Aircrew)

10

12

Fig 3.
2.
The second example given below details the DASORs raised against Typhoon at RAF
Coningsby during the period 1 Jan 31 Mar 11. A comparison is given against the previous
quarter and also the same quarter in the previous year. In this case the major system groups
have been used to indicate the type of occurrence. Fig 4 6 Refers.
Coningsby - Typhoon DFSORs 1 Jan - 31 Mar 11

Role Equipm ent

Incident
3 Sqn

Oxygen
Fuel
Flying Controls
Flight/Nav Attack
Engine

Incident
29 Sqn

Electrical Power Supply

Com m unications
Braking
Alighting Gear

Incident
11 Sqn

Airfram e
Air Conditioning

No of Incidents

Fig 4.

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Coningsby - Typhoon DFSORs 1 Oct - 31 Dec 11

Oxygen

Incident
3 Sqn

Hydraulic Power
Flying Controls
Flight/Nav Attack
Engine

Incident
29 Sqn

Electrical Power Supply

Com m unications
Braking

Incident
11 Sqn

Alighting Gear
Ai f

No of Incidents

Fig 5.
Coningsby - Typhoon DFSORs 1 Jan - 31 Mar 10
Oxygen

Incident
3 Sqn

Fuel
Flying Controls
Flight/Nav Attack

Incident
29 Sqn

Engine
Electrical Power Supply
Com m unications

Incident
17 Sqn

Braking
Alighting Gear

Incident
11 Sqn

Airfram e
Air Conditioning

No of Incidents

Fig 6.

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200.105
AIR SAFETY OCCURRENCE REPORTING

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200.105

AIR SAFETY OCCURRENCE REPORTING

INTRODUCTION
200.105.1
This chapter describes the procedures laid down for reporting RAF aircraft accidents,
incidents and occurrences and is supplementary, and subordinate to, the Defence occurrence
reporting requirements set out in MRP RA 1410. All personnel shall adhere to MRP RA 1410 and
this order.
AIM
200.105.2 The aim of Defence occurrence reporting procedures is to provide for the rapid
identification of the causes of air and ground occurrences, and of the actual and potential Air
Safety hazards associated with incidents and hazard observations, so that the appropriate action
can be taken to prevent any recurrence and minimise risk.
REPORTING RESPONSIBILITY
200.105.3 In accordance with RA1410 and this order, all RAF personnel 1 are required to report
an occurrence, incident or accident which may affect Air Safety. A single nominated individual may
report such an occurrence on behalf of a group (eg Captain or Mission Commander may submit a
D-ASOR on behalf of a crew or flight).
200.105.4 Where the occurrence occurs away from base and it is impracticable for the parent unit
to initiate reporting action, RA1410 details reporting responsibilities.
200.105.5 Scope.
a.
The following RAF flying, and all activity in direct support of such flying, is covered by
this order:
(1) Aircraft under the command and control of the RAF, whether civilian or military
registered.
(2)

RAF assets assigned to JHC.

(3)

Air Cadet Gliders.

(4) Activity in aircraft simulators that may have relevance to operation of the real
aircraft.
b.
AT sport air activity, such as that carried out by the Joint Services Adventurous Training
Gliding organization (JSAT(G)), is not covered by this order. Such activity should be treated
as civilian flying, even though participants may be on duty. AOC 22 (Trg) Gp as the Senior
Responsible Officer for JSAT(G) activity should specify any additional reporting
requirements.
c.
RAF Gliding and Soaring Association (RAFGSA), RAF Microlight Flying Association
(RAFMA), RAF Flying Club Association (RAFFCA), and other RAF Sport flying or sport
parachuting are also treated as civilian activities and occurrence reporting is to be carried out
iaw the CAA, FOBs and other local orders/arrangements. RAF Stn Occurrence Managers (or
Airfield Mgrs) hosting such activities are to ensure that a D-ASOR is submitted to record any
serious accident or incident occurring at or in the vicinity of the airfield, noting that the
incident has been referred to the CAA (and/or) AAIB for follow up action.
1

Including members of the Air Cadet organisation, contractors working for the RAF, and other forces operating under RAF control.

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d.
Where accidents or serious incidents involving civilian aircraft occur at, working from or
under an RAF unit or in the vicinity of an RAF unit, particularly where PCM action has been
initiated by a unit, the unit should inform the HQ Air DO (see 200.105.11) and submit a DASOR.
200.105.6 Non-RAF Aircraft. Accidents or serious incidents to aircraft outside the scope defined
at 200.105.5, which occur at, working from or under an RAF unit or in the vicinity of an RAF unit,
should be reported in accordance with Section 200.145.
REPORTING PROCEDURES
200.105.7 Definitions Guidance. Accidents, incidents and occurrences are defined in the MRP
Master Glossary (MAA02).
200.105.8 Occurrences Arising from Hostile Action. Occurrences arising from hostile action
are to be completed in accordance with the instructions at RA 1410 and AP3207 Section 200.140.
200.105.9 Sensitive Operations. Accidents, incidents and occurrences that occur during
sensitive operations are to be reported via D-ASOR to the greatest extent possible within the
UNCLASSIFIED bounds of ASIMS.
200.105.10 Accidents. The following reports are required in the event of an accident not in an
Operational Theatre:
a.
Initial Report (Immediate) In the event of an accident, the reporting person/unit shall
immediately notify the MOD Deputy Chief of Defence Staff Duty Officer (DCDSDO) on 9621
88938 / 0207 218 8938 (manned 24 hours). Information shall be passed iaw Annex A.
Subsequent cascade of information (eg To the MAA, HQ Air Staffs and the ODHs) shall be
carried out by the DCDSDOs.
b.
D-ASOR (within 24hrs). A D-ASOR must be raised and accepted on ASIMS within
24hrs of the accident.
The Initial Report (Immediate) will be cascaded iaw DO orders and will be undertaken by staff at
each level (MOD, HQ Air, Gp and Stn) for internal UK Defence. If the report is likely to affect other
Air Forces or aviation communities out-with UK Defence, RAF FS will disseminate appropriately
redacted information. Once the DO has completed the immediate reporting requirements,
including completing the Initial Report (immediate) to the fullest extant possible, the DH
responsible for the platform or aviation system being reported, must ensure all relevant personnel
are kept informed, via e-mail, of progress. A minimum distribution list and Follow-up Report format
is provided at Annex B. This is in addition to the routine D-ASOR activity.
For Accidents in an Operational Theatre, the Initial Report (Immediate) must be made to the PJHQ
Duty Ops Controller on 9360 55310.
200.105.11
Significant Occurrence Notification (SON). In the event of a Significant
Occurrence, notification must be made to the MAA 2 and HQ AIRDO 3 so that timely decisions can
be made whether or not a Service Inquiry (SI) or Non-Statutory Inquiry (NSI) are required.
Occasions requiring SON include, but are not limited to, one or a combination of the following:
a.
Air Safety occurrences that have either led to, or may at short notice lead to, the
suspension of flying operations.
2

IAW RA1410, ODH and PTL staff are required to contact MAA Knowledge Exploitation Branch via telephone (030 679 84190 or
84191) during working hours, or to the MAA DO (07799 772101) out of working hours
3
GPTN - 95221 4072, Civil 01494 564913.

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b.

There has been a Major Injury as defined by RIDDOR 4 .

c.

Damage to the platform or equipment is classified as Repair Category 3, 4 or 5 5 ; 6 .

d.

When it is considered that a potentially serious Air Safety risk may exist.

e.

When VIPs or Civilian passengers are involved, or there is media or ministerial interest.

f.
Air Safety occurrences that have resulted in, or may require, a significant restriction
being imposed on the platform or equipment in use.
Additionally, an SON should be sent to the HQ Air Command AIRDO (not the MAA) for an overdue
aircraft, particularly when the outcome is likely to remain in doubt for some time.
When SON reporting occurs to the HQ Air Command AIRDO, the SON should follow the format of
the Initial report (Immediate) (at Annex A) as close as practicable.
200.105.12
Reporting of Other Flight Safety Incidents and Occurrences. All other
reportable occurrences 7 in which Air Safety was compromised must be reported on a D-ASOR
within 2 working days. Within this timescale the D-ASOR must be distributed by the Occurrence
Manager, having passed through the Technical/ Supervisor Stage, regardless of whether or not it
is complete. The information contained within the D-ASOR must allow other organizations to
understand the key circumstances of the incident.
200.105.13
Hazard / Observations. Some occurrences do not fit into the list of reportable
occurrences, because no event actually occurred, but nonetheless they are still of interest to the
Defence Aviation Community; these occurrences are often called near-miss events or, more
accurately, Hazard Observations. Such occurrences are those where Air Safety was not
compromised but the potential for Air Safety to be compromised in the future was recognised.
Hazard Observations with Air Safety implications must be reported using the D-ASOR.
200.105.14
RAF AEMS. The RAF AEMS form 8 is an alternative method of reporting a
Hazard/Observation or Near-miss. RAF AEMS Forms are to be made available at all RAF
locations that undertake aviation activity. Specialist personnel will assess the content of all RAF
AEMS forms submitted and those identified as being Air Safety related will be captured into ASIMS
as a D-ASOR.
200.105.15
Specialist Reporting Procedures. Depending on the type of occurrence,
additional specialist reporting sections may be required to be completed with a D-ASOR. The
occurrences that require additional reports are listed in RA 1410, examples include AIRPROX (see
200.110 for further detail), MALDROP, Birdstrike and Fatigue. The following
information/procedures are to be followed where an additional section is not available on ASIMS:
a.
Lightning Strike. All lightning strikes and cases of severe static discharge are to be
reported by D-ASOR and are to include the information detailed at Annex D.
b.
Armament Accidents and Incidents. In addition to a D-ASOR, armament accidents
and incidents which are the cause of (but not the result of) an air or ground accident/incident
are to be reported in accordance with Chapter 25 of JSP 482.
c.
Aircraft Wreckage Reports. When aircraft fragments or material thought to be RAF
property are handed in or reported to an RAF station by the finder, police, or Receiver of
Wrecks, reporting action is to be taken on a D-ASOR and in accordance with Annex E.
4

See www.hse.gov.uk/riddor for full definitions. A summary is at Annex A.

Repair work is considered by the custodian to be beyond their forward maintenance organization capabilities.
6
Category 4 and 5 damage requires an SI to be convened.
7
Listed at Annex C to RA1410.
8
AEMS Form is at Annex C.
5

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However, when the wreckage is obviously only of historic interest, eg Second World War
aircraft, the matter should be referred to the RAF Historic Branch, RAF Northolt (+44 20
88338175).
UPDATES TO REPORTS.
200.105.16
Occasionally it may not be possible to provide all the necessary information
within the 48hr release timescale for the D-ASOR. In this event, it is most important that the DASOR be despatched on time with an annotation that follow up action/activity is under way and
additional information will be entered (by means of the Occurrence Manager editing the DASOR)
as soon as possible. Should an Occurrence Safety Investigation (OSI) be convened, progress
reports should be recorded as Comments on the initial D-ASOR at least every 30 days iaw
AP3207, 200.120. These procedures are in addition to the Follow-Up Report 9 requirements.
CONFIDENTIAL REPORTING PROCEDURE
200.105.17
It is important that the RAF has visibility of all occurrences and hazard
observations in order that valuable lessons can be identified. If an individual is concerned about
raising an issue to his/her immediate superiors or colleagues they may chose one of the following
confidential reporting procedures to highlight the event:
a.
AEMS Form. By selecting the box I wish my details to remain confidential and
sending the form direct to the SEMSCo, the individuals anonymity is guaranteed and will
only be released with his/her consent.
b.
Defence Confidential Occurrence Report (DCOR- Previously CONDOR/MURPHY).
The DCOR reporting system allows personnel to report occurrences, hazards and human
error incidents confidentially direct to SO1 RAF Flight Safety. The DCOR can be found on
both the MAA and RAF FS website and procedures for completion and reporting are in RA
1410.
Whilst anonymous reports will still be staffed, they are less likely to be concluded satisfactorily and
feedback to the individual can not occur.
ANNEXES TO CHAPTER Section 200.105
A.
B.
C.
D.
E.

Initial Report (Immediate).

Follow-Up Report
AEMS Form Local Form 001.
Lightning Strike Report.
Reporting, Investigation and Disposal of Aircraft Wreckage Found or Landed within the UK.

200.105.10 and Annex B to this order.

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ANNEX A TO
ORDER 200.105

INITIAL REPORT (IMMEDIATE)

It is essential that the Initial Telephone report is made as soon as possible so that MOD Duty
Personnel can alert the other many key personnel who will need to take action. Those details
required at paragraphs 4 and 6 are particularly important to the Air Command Business Secretariat
who deal with Parliamentary and Press enquiries. The report must be updated as more
information becomes available.
Telephone Numbers
Period

Tel No

Addressee

Manned 24 hours

DCDSDO

GPTN
9621 88938

BT
0207 218 8938

Format
1.

Person Reporting

Name
2.

3.

4.

Station

Tel No

Occurrence
a.

Brief Outline (possible cause).

b.

Time.

c.

Height and Speed.

d.

Weather.

e.

Height and Speed of Ejection/Abandonment.

f.

SAR action.

Aircraft Details
a.

Type/Mark/Number.

b.

Parent Unit and Station.

c.

Purpose of Flight.

d.

Persons on Board.

e.

Aircraft fit (Weapons Training/Operational).

f.

Classified Equipment on Board.

Wreckage/Ejection Sites

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5.

a.

General description.

b.

Accurate Grid Refs.

c.

Name and Position of nearest farm or village or town.

d.

Weather conditions.

Service Personnel

Rank

6.

7.

Name

Number

Branch/
Trade

Eject/
Aband

Injury

Kinform
Kinnot

Civilian Aspects
a.

Civilian Casualties.

b.

Civilian Damage.

c.

Proximity of nearest building.

d.

Proximity of nearest school, hospital or other sensitive building.

e.

Press Interest.

Message Timed At:

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ANNEX B TO
ORDER 200.105
FOLLOW-UP REPORT
The Senior leadership must be updated of on-going action for accidents or SONs that have been
reported iaw 105.10 and 105.11. As well as the routine D-ASOR actions, the DH responsible for
the platform or aviation system that had the accident or SON must e-mail detail of the on-going
action in the following format, to the addressees below (as a minimum). This is to be completed on
a weekly basis (by COP Friday) until such time as a decision is taken to complete an SI or NSI,
resume flying or as directed by the SDH Snr Op.
Note For IFS and all Gps, the individuals and the Multiuser accounts must be copied in.
Addressees:
SDH
SDH Snr Op
SDH Chf Eng/XO
ODH 1 Gp
ODH 2 Gp/COS Ops
ODH 22(Trg) Gp
IFS

DG MAA
Hd DE&S
ACAS
CJO
Comd JHC

Accident/SON D-ASOR Reference (if known)

Description of event:

Actions Taken: eg suspended flying, issued DHAN#

Actions underway:
Next report date:
Attachments:
Notes:

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ORDER 200.105

Aviation Error Management System Report Form

When to Report: Any event, hazard, near-miss or situation which you believe could or
did contribute to an error being made and, as a consequence, affect air safety.
What to Report: Procedural inaccuracies/ambiguities, mismatches between required
and actual practices, work pressures, I didnt have this..., they did this.. and I
nearly did this. are examples of what could be reported. Please include as much
detail as possible in order to aid understanding of the reported issue.
Why do you want my details: So that we can get back to you about your report and also
if we need more information.
Where to send this report: Once completed, forward this form to your Local Error
Management System Coord unless you have ticked the confidential box in which case the
form is to be sent directly to the Station Error Management System Coordinator
(SEMSCo).

Name:

Date:

Contact No:

E-Mail:

Section:

Details:

I wish my details to remain confidential

Report Serial No (for use by SEMSCo)

RAF Flight Safety Local Form 001 Issue 4

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ORDER 200.105
FORMAT LIGHTNING STRIKE REPORT
The D-ASOR should contain all of the following information. If this is not possible, send a
completed Lightning Strike Report iaw this Annex, attached to the relevant D-ASOR to:
DE&S, Flight Systems Department, Abbey Wood.
Incident Details
Aircraft & Ser No
Date Day/Night
(a)
Height
(b)
IAS
(c)
OAT indicated/corrected
(d)
Terrain below
2
(a)
In or out of cloud
(b)
If out of cloud VMC or IMC
3
(a)
Cloud type
(b)
Cloud cover
(c)
Cloud tops
(d)
Cloud base
(e)
CCWR indication
if applicable
(f)
Thunderstorm warnings
4
Precipitation
5
Turbulence
6
(a)
Any other lightning
activity before or after
(b)
Any static activity before
Or after visual, on comms
7
Head up or down
8
Loudness of bang
9
Brilliance and position
of flash
10 (a)
Aircraft jolt
(b)
Control movement
11 Any smell
12 Any effect on crew (eg blindness, electric shock,
sickness, muscular or headache, numbness,
disorientation)
13 Any aircraft systems affected
14 (a)
Degree of damage
(b)
Engineering officer in charge
15 Diagram showing position of strikes on aircraft
16 Remarks
1

Pilot Sqn Station

DRA Inc No
(e) A/c attitude and
configuration

17 Contact telephone number of reporter

Note 1 Tornado and Typhoon Units only:
An ADR printout, dated and serial numbered, is to be attached for DRAs use.
The printout should be a graphical trace (plot) of all parameters covering the
period 5 mins before to 5 mins after the lightning strike; if the time of strike is
indeterminate the whole plot is required.

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ORDER 200.105
REPORTING, INVESTIGATION AND DISPOSAL OF AIRCRAFT WRECKAGE FOUND OR
LANDED WITHIN THE UNITED KINGDON
1.
Fragments or pieces of wreckage may provide valuable clues to the cause of unsolved
accidents and may also be the means of identifying missing aircraft. Before claiming the material,
MOD has to decide whether it is MOD property and, if so, whether it is of sufficient use and value
to justify the cost of recovery. This may include a payment of salvage remuneration to the finder
for services rendered and possibly compensation for loss or damage to property. Units are not
therefore to enter into any commitments until instruction to do so have been received from
IFS(RAF) via commands.
2.
Any RAF unit receiving information on recovered material is to send a representative to view
the material and prepare a D-ASOR giving as much information as possible, through ASIMS,
including the following information:
a.

Description of item(s) including condition and estimated weight.

b.

Opinion on whether the material is RAF property.

c.
Type of aircraft concerned, fin number if known and date or approximate date of crash
if known.
d.
Opinion on whether the material should be claimed by MOD having regard to its
possible use, value or historic interest.
e.
Where the material was found and by whom, and whether claims for compensation or
recovery costs could result if the items were claimed by the MOD.
3.
The D-ASOR is to be sent to the senior safety office (eg 2 Gp STR) of the parent group who
is to decide whether it is necessary to take any other action, eg consult the RAF Museum. If it is
decided that the material is of no use or interest, the senior safety office is to inform the unit that it
can be disposed of as scrap.
4.
If it is decided that the material could be of use to the Royal Air Force and the MOD decides
to claim the material, the gp safety staff are to instruct the unit concerned to arrange for it to be
collected. The unit is to store the material in safe custody until further instructions for disposal are
received. A statement showing expenses incurred in recovering material is to be obtained for MOD
Naval Law Division.

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200.110
TYPES OF AIR SAFETY INVESTIGATION

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200.110

TYPES OF AIR SAFETY INVESTIGATION

INTRODUCTION
200.110.1 The thorough investigation of aircraft accidents and incidents is essential if
recurrence is to be avoided. The objectives of an Air Safety Investigation are to:
a.

Determine the cause(s) and contributory factors.

b.

Recommend effective intervention(s) to prevent recurrence.

c.

Highlight any other lessons learned.

The investigation is not to apportion blame. The type of investigation carried out following
aircraft accidents, incidents, and other Air Safety related occurrences (including BM,
Engineering and Direct Support Services issues) will vary depending on the nature of the
occurrence.
MAA SERVICE INQUIRY
200.110.2 Accidents and major incidents are normally investigated by the MAA via a
formal Service Inquiry (SI). Procedures for an SI are laid down in JSP832 and MRP
RA1420. Section 200.115 outlines the RAFs responsibilities.
NON-STATUTORY INQUIRY
200.110.3
A Non-Statutory Inquiry (NSI) may be ordered by the CO of the station or
unit concerned, or by a higher authority in order to investigate an accident, incident or
occurrence which warrants formal investigation, but does not justify the convening of a SI
by the MAA1. By exception, the SDH (through IFS) or the relevant ODH may direct the
convening of an NSI. Within the Air Safety environment, an NSI is to be conducted iaw
with the procedures for Occurrence Safety Investigations (OSI) at Section 200.120.
AIRPROX INVESTIGATIONS
200.105.4 Units are required by RA 1410 (Guidance Material) to investigate the
involvement of their aircraft/personnel in any Airprox. Whilst all Airprox reported in UK
airspace are investigated by the UK Airprox Board (UKAB) as detailed in the RA., an initial
investigation and examination of reported events is required to ensure full details are
captured ,so that it can be assessed whether there is a requirement for an SI, NSI, or
SON reporting (iaw 200.105 and RA1410).
a.
UKAB Investigations. UKAB procedures do not negate the requirement for
DHs (or Aerodrome Operators2) to investigate and address safety issues within their
own organizations if deemed appropriate The UKAB focuses on identifying a cause
and severity, recommendations are made by exception, and the UKAB may take
several months to deliver an output..

ESARR 2 (Reporting & Assessment of Safety Occurrences in ATM) mandates that all occurrences involving BM personnel that are
assessed as BM Severity Category 4 or above shall be investigated.

Term to be ratified by the MAA.

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b. Initial Unit Research. A units initial enquiries should ensure that detailed and
timely pilot reports are included on the D-ASOR, as well as any immediate corrective
actions taken locally on the basis of the available information; these details assist the
UKAB enormously in their consideration of the event. This initial data-gathering
should determine whether the OSI process needs to be followed and should involve
liaison with UKAB, Gp or RAF FS staffs if necessary.
c. OMs, guided by their DH (or Aerodrome Operators) should consider whether an
OSI is appropriate following the initial research of the circumstances. Airprox are
often the most serious occurrences involving RAF aircraft and units investigative
effort should be apportioned accordingly. Where other parties to an Airprox are
readily identified, they should be contacted so that lessons can be identified quickly.
If this is not possible, final consideration of an Airprox may need to await the outcome
of the UKAB, noting that detailed recommendations are unlikely to be forthcoming.
Whilst a units investigations may be concurrent with the UKABs, the UKAB will
normally await the outcome of an OSI before making their final assessment of an
Airprox.
JOINT INVESTIGATIONS
200.110.5
RAF/NATO Combined Inquiry. Accidents or incidents which involve
aircraft, equipment, or personnel of the RAF and one or more NATO forces may be
investigated by a NATO combined investigating committee under the terms of STANAG
3531. The MAA shall have primacy in the investigation of accidents or incidents under
their authority to convene SIs. However, the RAF may directly be a party to any
RAF/NATO Combined Inquiry using the procedures set out in Section 200.125.
200.110.6
RAF/Civil Parallel Investigations UK. Regulations exist which permit
the AAIB to investigate accidents involving both military and civil resources. A RAF liaison
officer may be invited to attend, but the AAIB inquiry is not regarded as a combined
inquiry; an MAA-convened SI will ordinarily be held in parallel when these regulations are
used. Details of the procedures are at Section 200.125, et seq.
200.110.7
RAF/Civil (or Non-NATO) Investigations Overseas. Overseas RAF
involvement in a civil or non-NATO accident, or serious incident, is subject to either a
MAA-convened SI or a RAF NSI (where the MAA has elected not to convene an SI). RAF
representation at any other investigation will be decided by IFS (RAF Flight Safety) in
accordance with Section 200.145.
200.110.8
Non-RAF Investigations. Accidents or serious incidents involving aircraft
of another Service or country, which occur at or in the immediate vicinity of RAF units, will
normally be investigated by the aircrafts operating authority. In all instances the RAF
should request an RAF observer to observe the investigation. The procedures are set out
in Section 200.145.

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200.115
RAF SERVICE INQUIRY PROCEDURES

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200.115

RAF AIRCRAFT ACCIDENT SERVICE INQUIRY PROCEDURES

200.115.1 INTRODUCTION
200.115.2 RAF Accident Service Inquiry (SI) responsibilities were assumed by the MAA on 10 Jul
10 in line with the Haddon-Cave Review. The associated transfer of SI convening authority (CA)
took effect on 01 Aug 10 and formalised the Military Air Accident Investigation Branch (MAAIB),
with the agreement of the Chiefs of Staff.
200.115.3 CONVENING OF SI. An SI will ordinarily be convened by the MAA for aircraft
accidents, when there has been a death or serious injury related to aviation activity. The MAA also
reserves the right to convene an SI under additional circumstances which it deems appropriate.
200.115.4 Routine SI Liaison between FLCs and MAA. General liaison between the MAA and
the relevant FLC Aircraft Operating Authority/DH will be with the FLC (IFS and ODH) Flight Safety
Staff. Routine FLC internal liaison with the chain of command, legal and secretariat as an Inquiry
is in progress will be facilitated via the DDH/ODH and RAF Flight Safety organisations.
200.115.5 Support from the FLCs. The current SI arrangements by which the RAF provides
support for kinforming, Aircraft Post Crash management, media handling, etc, will remain
unchanged. While it will be necessary, and may even be helpful, to announce that the SI is
underway, the SI is to work in the background with a passive/reactive media posture.
Circumstances may dictate that the MOD or RAFs postures may be different, in which case it is
important to ensure that the internal lines of communication are clearly established and
understood. Throughout, the existing roles and experience of the Single-Service Inquiry Coordinators 2 should be drawn on.
200.115.6 AOA/DH Observers. The SI Panel President will report directly to the MAA Convening
Authority (CA). However, the benefits of arrangements to enable the AOA/DH to quickly address
emerging SI Panel findings of immediate relevance to FS and airworthiness are recognised by the
MAA. Therefore, in order to retain their ability to respond promptly to any such findings, AOAs/DHs
will be invited to nominate an SI Panel Observer. Such a nominated individual will be required by
the MAA to act under rules of privilege, and will be granted visibility of the Inquirys proceedings in
order to highlight any key FS/airworthiness issues to help prevent re-occurrence. The SI president
will routinely be given written delegated authority to release such information, when requested by
the AOA/DHs Observer.
200.115.7 Final Report, and RAF Comment and Follow-Through. Once the SI President has
submitted the draft SI Report, the MAA, as CA, will draft Regulator Comments and
Recommendations, which will include Action responsibilities and associated milestones. As
independence and coherence of accident responses are now underpinned by an independent
MOD Authority (MAA), formal comment by the RAF is not permitted as a Reviewing Authority.
However, the CA will disclose the final draft Report to the RAF COS/DHs, solely for comment on
errors of fact, opsec issues and implementation of recommendations, before final CA comments
are added and the Report is finalised. Thereafter, the MAA and IFS (RAF Flight Safety) will
monitor the implementation of Recommendations by the DDH and ODH.

Detailed in JSP 832 Chap 1 Annex A.

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200.120
OCCURRENCE SAFETY INVESTIGATION

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200.120

OCCURRENCE SAFETY INVESTIGATION (OSI)

INTRODUCTION
200.120.1
The aim of undertaking an OSI is to not only establish what happened but
more importantly why it happened the root cause or causes and the factors that
contributed to the event. This knowledge will allow for the formulation of error/event
prevention strategies or interventions that should reduce the likelihood of reoccurrence.
The OSI should not apportion blame, nor should it contain overt criticism of any personnel.
200.120.2
The OSI consists of two parts: the investigation (Annex A) and the
Occurrence Review Group (ORG). The investigation is undertaken as a non-judgmental
investigation by trained investigators who have an increased awareness of Human
Factors. The ORG provides the opportunity to formally review, and consider the quality of
the findings of the Investigation and the interventions suggested by the investigators. In
addition the ORG, which normally sits outside of the direct command chain of individuals
involved, may form a judgement on culpability. Any administrative/disciplinary action taken
by line management is to be outside of the OSI process.
200.120.3
Convening Authority. An OSI may be ordered by the SEMSO 1 of the
station or unit concerned or by a higher authority. Where the SEMSO is not the DDH, the
DDH should be consulted. Nevertheless, the DDH (or exceptionally the ODH or SDH)
retains the right to convene his own investigation for a deployed unit as he retains the
Operating Risk. Where multiple units or force elements are involved, relevant DDHs and
COs should nominate a mutually agreeable Convening Authority. For OSI involving force
elements deployed on operations, the OSI may be convened by EAW COs. In this
instance relevant DHs should be consulted on all matters regarding the convening and
reporting of such investigations.
200.120.4
Convening an OSI. It is the responsibility of the Convening Authority, via
2
the SEMSCo , to issue the Lead Investigator with Terms of Reference which is to contain
the information at Annex B as a minimum. The Investigation Team should assemble no
later than two working days from when a decision is taken to convene an OSI.
200.120.5
Confidentiality. Occurrence Investigators (OIs), support team personnel
and ORG members are not to communicate deliberations and/or findings of an OSI to any
person, at any time, unless authority has been given by the Convening Authority.
INVESTIGATION
200.120.6
Constitution. The Team should consist of a minimum of two OIs: the
Lead Investigator and at least one other member. The OIs must hold the Flight
Safety|Occurrence Investigator(OI)|Joint competence and be current to undertake an
investigation 3 .

Station Error Management System Owner. This position is to be filled by the Stn Cdr/DDH/Head of Establishment/((Aerodrome
Operator) to be ratified by the MAA).
2

Where a Stn has yet to receive AEMS training this position is to be filled by the SFSO.

A minimum of one investigation in the preceding 6 months carried out to the satisfaction of the SEMSCo.

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a.
Lead Investigator. The SEMSO is to decide the appropriate rank/trade of the
Lead Investigator depending on the nature and seriousness of the incident and the
profile of the investigation.
b.
Other Members. The OIs who will act as Members of the investigation, will be
selected at the discretion of the SEMSCo and may or may not be specialists in the
field relating to the nature of the incident.
Should an OSI be required at a stn where there are no trained OIs or trained OIs are not
available the investigation can be conducted and recorded iaw the requirements stated in
Annex C. RAF Stations operating RAF AEMS who wish to conduct an OSI iaw Annex C
are to request authority to do so from IoFS.
200.120.7 Evidence on Oath. Evidence at an OSI is not to be taken on oath. In extremist
both Defence Legal Services and RAF Flight Safety must be consulted prior to any
evidence being taken on oath.
200.120.8 Professional Reputation/Character/Legal Implications. If at anytime during
an interview:
a.
The Lead Investigator considers it likely that a persons character or
professional reputation may be in question or that there may be legal implications the
Lead Investigator is to stop the interview and seek advice from the SEMSCo.
b.
The interviewee expresses concern that the information he/she is giving may
affect his/her professional reputation, character or have legal implications the Lead
Investigator is to explain the OSI process and the RAF Just Culture policy. If the
interviewee still has concerns, the Lead Investigator is to stop the interview and seek
advice from the SEMSCo.
200.120.9 OSI Procedure.
a.
OI team members should be released from their normal duties for the duration
of an investigation. For matters wholly concerned with an investigation, OI team
members will, via the Lead Investigator, be responsible to the SEMSO via the
SEMSCo.
b.
OI team members are to be afforded all due assistance during the course of an
investigation. This may include:
(1) Gathering of suitable evidence. This may include verbal/written statements
given during an interview process, relevant data and/or records and multi-media
considered appropriate by the Lead Investigator.
(2)

IT support.

(3)

Suitable location in which to conduct interviews.

c.
No constraints are to be imposed upon the investigation process unless
considered essential by the SEMSO.
d.
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to assist with an investigation in the role of support team personnel. Support team
personnel should be released from their normal duties when assisting the
investigation team.
e.
Unless forming part of the investigation team SMEs are not to be involved in the
investigation process other than to provide specialist advice to the investigators.
f.
On completion of the investigation, the Lead Investigator is responsible for the
compilation of the OSI(RAF) Format Annex A.
200.120.10
Information Security. The security of data and information gathered
during the investigation is the responsibility of the Lead Investigator until handed over to
the SEMSCO whereupon this responsibility is transferred to the SEMSCo.
OCCURRENCE REVIEW GROUP 4
200.120.11
The ORG aims to reduce individual and organisational error by ensuring
that effective and sustainable interventions are taken in response to occurrence
investigations, combined with the consistent application of the RAF Just Culture 5 .
200.120.12
Convening an ORG. The Convening Authority is to convene the
subsequent ORG on completion of the investigation element of the OSI.
200.120.13
ORG Constitution. An ORG is to comprise of three SQEP 6 members (a
chairperson and 2 members). When selecting the Chairperson and members for the ORG
the Convening Authority is to take into consideration the severity, or potential severity, of
the occurrence, the rank of the personnel involved and the ability of the Chairperson to
agree on the likely recommendations suggested by the Lead Investigator. ORG members
should not be in the direct chain of command of any individual highlighted in the
Investigation. Should an OSI be required at a stn where there are no trained ORG
members, assistance to identify external SQEP ORG personnel may be requested by the
Convening Authority from the Regional Aviation Error Management System
Coordinator(REMSCo).
200.120.14
ORG Assistants. Any person can be asked to advise an ORG. Persons
may include the Lead Investigator of the investigation, a SME (to provide specialist advice)
or contractors associated with an activity. The advisors are bound by the same rules of
confidentially as members of the ORG. All advisors are to depart the ORG prior to the
deliberation phase. Under no circumstances shall any person, other than
authorised members of an ORG be part of, or attempt to influence, the deliberation
phase of an ORG.
200.120.15
Anonymity. If the identities of the personnel related to the event are
known to any member of the ORG this should be highlighted to the Convening Authority
prior to the start of the ORG. If the Convening Authority believes that this may prejudice
the objectivity of the ORG the composition of the ORG must be changed.
4

ORGs can only be undertaken following investigations conducted by personnel who have trained investigators.

AP 3207 Order 200.135 Just Culture.

Member of the ORG must hold the Flight Safety|Occurrence Review Group (ORG)|Joint competence. Until Apr 2015 individuals who
hold the Flight Safety|Occurrence Review Group (ORG)|RAF competence may also undertake ORG duties. Ideally the Chairperson
should have sat on at least 2 ORGs as a member.

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200.120.16 ORG Responsibilities.

a.
Prior to ORG. Prior to attending the ORG, the Chairperson is to receive a brief
from the SEMSCo on his duties wrt the ORG and receive their TORs, at Annex D.
Guidance. It is good practise for the ORG Chairperson and Members to receive a
copy of the OSI (RAF) Form a few days prior to the start of the ORG. The ORG
Chairperson can then request SME support and provide a list of likely questions.
They may also request the presence of the Lead Investigator of the investigation if
required to clarify any points. This should speed up the deliberations; however,
care must be taken not to attend the ORG with preconceived ideas or bias.

b.
OSI(RAF) Form Review. Only information gathered through the associated
investigation is to be used by the ORG in its deliberations. The ORG is to review the
OSI(RAF) Form and resultant recommendations to determine whether:
(1) The form clearly states the occurrence being investigated and records the
conduct and findings of that occurrence.
(2) The Investigation has established the root cause of the event, as far as
reasonably practicable.
(3) The recommendation(s) address all the causal/contributory factors
identified in the investigation.
(4) The recommendation(s), when implemented, will be effective and
sustainable. The ORG may amend any recommendation to increase its
effectiveness or sustainability. To assist an ORG in satisfying this requirement
an ORG is to have access to records of any previous investigations of similar
occurrences and the interventions taken.
(5) Any additional recommendations should be made to prevent reoccurrence. The ORG should satisfy itself that these recommendations are
effective and sustainable.
After discussion with the Lead Investigator and SEMSCO, if the ORG Chairperson
determines that the investigation does not satisfy the requirements of 1 -3 above, the
investigation is to be returned to the Lead Investigator for completion.
c.
Determination of Culpability. Any culpability is determined by application of
the RAF Just Culture policy 7 . It is essential that during this process the anonymity of
any person(s) involved in the event is maintained so as to remove or reduce any
possibility of bias that members of an ORG may possess; if this cannot be assured
the ORG member is to state their awareness of the individual(s) to the ORG
Chairperson.
d.
Recording of Decisions. On completion of an ORG, the ORG Chairperson is
responsible for ensuring that the ORG Record of Decisions and Comment form, at
Annex E, is completed and passed to the SEMSCo for administrative action.
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OSI STAFFING
200.120.17 Reporting.
a.
Interim Report. The requirement to issue an interim report should always be
considered when the investigation is likely to have wider implications. When
required, an interim report should be issued within 48 hours of assembling; the
Interim Report should be entered in the original D-ASOR. If the complexity or
sensitivity of information renders it unsuitable for inclusion in the DASOR, redacted
information should be attached. Consideration of further reports should be made
when new information is available.
c.
Follow up Reports. During prolonged investigations it will be necessary to
provide follow-up reports to advise higher authority of progress. A report should be
recorded on the original D-ASOR at least 30 days after the OSI is convened, and
every 30 days thereafter.
A copy of any interim and follow-up reports are to be forwarded to affected Group
Headquarters and RAF Flight Safety. Further distribution, through ASIMS Role Groups,
should include the platform internal role group and other ODH role groups.
200.120.18 Disciplinary/Administrative Action. Where a level of culpability is
determined iaw the principles of the RAF Just Culture policy against any individual(s)
involved in the occurrence investigated, then this determination is to be sent to the Line
Manager(s) of the Individuals via the DH Review Group. Disciplinary action must occur
outside any OSI procedure. Other than the level of culpability determined by the ORG,
details of further action taken is not to be contained within the D-ASOR, supporting
comments and attachments. The OSI should be released as soon as possible after
conclusion.
200.120.19 Record of Investigation. The completed OSI (OSI (RAF) Form and ORG
Record of Decisions) is to be attached to the original D-ASOR. Before completing this
action the SEMSCo is to ensure that it is of a suitable security classification and neither
refers to individuals nor explicitly attributes blame.
200.120.20 Recommendations. The recommendations accepted by the ORG are to be
uplifted into ASIMS and linked to the original D-ASOR. Each recommendation must be
evaluated by the relevant DH Review Group to ascertain further actions; the DH review
group will accept, reject, or transfer the recommendations iaw the procedures at RA1410.
200.120.21 Distribution of the OSI. A copy of the final report and recommendations are
to be forwarded to affected Group Headquarters. Further distribution, through ASIMS Role
Groups, should include the platform internal role group and other ODH role groups. This
distribution list may be reduced at the discretion of the Convening Authority or higher
headquarters.
200.120.22 Comments by Convening and Higher Authorities. Comments by
Convening or Higher Authorities are to be recorded in the comments box of the original DASOR. Where more than one unit was involved in the investigation the Convening
Authority should ensure that each Unit Commander has the opportunity to comment on the
OSI. Where appropriate the OSI should be staffed to the respective ODHs for comment.
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200.120.23 Feedback.
a.
Feedback to Originator. Any decision made by an ORG in which no
culpability is determined is to be passed to the SEMSCo for communication to the
originator.
b.
Action on Recommendations. Recommendations worthy of wider publicity
are to be highlighted by the ODH so that RAF Flt Safety may take further appropriate
action regarding publicity.
ANNEXES TO CHAPTER SECTION 200.120
A.
B.
C.
D.
E.

OSI (RAF) Form.

Terms of Reference Occurrence Investigator.
Investigation Guide.
Terms of Reference Occurrence Review Group.
Occurrence Review Group Record of Decisions and Comments.

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ANNEX A TO
ORDER 200.120

Occurrence Safety Investigation (RAF) Form

Part 1
DASOR REF No.

Date of Occurrence

Part 2
Lead Investigator
Lead Investigator Contact Details
Date OSI Commenced
Date OSI Completed by Lead Investigator
Total Manhours Expended during OSI

Part 3: Personnel Information

Aircrew
TAG

Rank/Title

Role

Rank/Title

Role

Hrs Last 30 Days Hrs Last 3 Mths

Hrs on Type

Total Hours

Endorsements

Other Info

ATC
TAG

Time on Console

Total Experience
(Years/ Months)

Maintenance
TAG

Rank/Title

Role

Time on Type

Total Experience
(Years/ Months)

Other info

Rank/Title

Role

Time on Type

Total Experience
(Years/ Months)

Other info

Other
TAG

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Part 4: Analysis

(Include Actor Tags w here necessary)

Summary of Investigation

Sequence of Events

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Part 4: Analysis Continued

(Include Actor Tags w here necessary)

Sequence of Events Continued

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Part 5: Findings

(Include Actor Tags w here necessary)

Occurrence Cause Factors

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Part 5: Findings Continued

(Include Actor Tags w here necessary)

Contributory Factors and Amplification. Note: The Contributory Factors are to be entered in an order that
best reflects their significance to the occurrence/incident/event. (See OSI (RAF) User Guide part 5.2 for further guidance)
Contributory Factor

Contributory Factor

Contributory Factor

Contributory Factor

Contributory Factor

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Part 5: Findings Continued

Observations

(Include Actor Tags w here necessary)

Note: List observations giving each a unique prefix reference.

Effects (if applicable)

Tick all that apply.

Aircraft or Equipment Damage

Down time

Hours/Days

Environmental Impact
Financial Cost

Manhours Expended

Hours

Personal Injury.

Hours/Days Lost

Flight Effect
No Effect
Effects - Further Details as Required.

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Part 6: Prevention

(Include Actor Tags w here necessary)

Event Prevention Strategies

What current existing procedures, processes, and/or policies in your organization are intended to prevent the incident, but didn't?

Inspection or Functional Check. Specify

Policies or Processes
(Specify)

Inspection or Functional Check

(Specify)

Maintenance Manuals
(Specify)

Operating Manuals

Loading Manuals/Sheets

Logbooks
(Specify)

Work Cards
(Specify)

Engineering Documents
(Specify)

Work Instructions

Other
(Specify)

Supporting Documentation
Service Bulletins
(Specify)

Training Materials
(Specify)

All operator Letters

(Specify)

Intercompany Bulletins
(Specify)

Other
(Specify)

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Part 6: Prevention Continued (Include Actor Tags w here necessary)

Event Prevention Strategies - Recommendations

List recommendations for event prevention strategies
Serial No.

Contributing Factor(s)
and Observation(s)

Recommendation/Prevention Strategy

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ANNEX B TO
ORDER 200.120

TERMS OF REFERENCE OCCURRENCE INVESTIGATOR (OI)

200.120.B.1 General Responsibilities
a.

You are responsible to:

(i) The SEMSO, via the SEMSCo, for undertaking OSI.
(ii) The Lead Investigator for the duration of the Investigation.

b.

You are responsible for:

(i) Conducting a Human Factor related Occurrence Safety Investigation to
identify the root cause(s) and contributory factors of the occurrence under
investigation. The cause(s) and contributory factors are to be identified iaw DASOR Classification System 8 .
(ii) Identifying the defences 9 already in place within the organisation that were
not effective in preventing the occurrence.
(iii) Identifying the behavioural type of individuals using the RAF FaiR Tool
Chart 1 10 .
(iv) Use the behavioural type identified to recommend effective/intelligent
interventions to mitigate the likelihood of reoccurrence.
(v)

Maintaining the confidentiality of all investigation findings.

c.
In addition to your responsibilities pertaining to an individual OSI as an OI you
are to attend OSI peer reviews at regular intervals but no less than one per year.
200.120.B.2 Lead Investigator Responsibilities. In addition to the responsibilities above
the individual nominated as the Lead Investigator of the Investigation is responsible for:
a. Highlighting any immediate Air Safety issues to the SEMSCo and the timely
production of the interim and any follow-on report deemed necessary by the SEMSO.
b.
The accurate and timely compilation of the OSI (RAF) Form 11 , iaw Annex D. On
satisfactory completion, the OSI (RAF) Form and all the evidence gathered during an
investigation is to be submitted to the SEMSCo.
c.

The security of all evidence, data and information gathered.

The D-ASOR Classification System can be accessed through the ASIMS Entry/Login Screen.

Defences include Training, Policies, Procedures and Processes.

10

AP 3207 Order 200.135.

11

AP 3207 Order 200.120 Annex C.

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d.
The conduct and administration of the investigation until the completed OSI
(RAF) Form has been handed over to the SEMSCo.
e.
The coordination of the OIs and support team members for the duration of the
OSI.
e.

Briefing the SEMSCo at least weekly on the progress of the investigation.

200.120.B.3 Training and Competency Requirements. The competencies required to

undertake the duties of an Occurrence Investigator are:
a.

Flight Safety|Human Factors Foundation Training|Joint.

b.
Flight Safety|Error Management Foundation Training|Joint or Flight Safety|Error
Management Foundation Training|RAF.
c.
Flight Safety|Occurrence Investigator(OI)|Joint. (The Flight Safety|Occurrence
Investigator(OI)|RAF competency should be automatically uplifted by JPA).
d.
To have completed at least one investigation to the satisfaction of the SEMSCo
in the preceding six months.

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ANNEX C TO
ORDER 200.120
INVESTIGATION GUIDE
Guide for Completing an OSI without Trained Investigators
200.120.C.1
Constitution. When no trained investigators can be located the
Convening Authority is to determine the constitution of the team. In making this decision,
the Convening Authority is to take into consideration the nature and seriousness of the
incident and the profile of the investigation.
200.120.C.2
Convening the Investigation. It is the responsibility of the Convening
Authority to issue the Lead Investigator of the OSI with specific Terms of Reference (TOR)
for the investigation. The TORs Matrix at Annex E to JSP 832 may assist the Convening
Authority in the generation of these TORs.
200.120.C.3
Confidentiality. Members of the Investigation Team are not to discuss
the progress or findings of an investigation to any person, at any time, unless authority
has been given by the Convening Authority.
200.120.C.4
Information Security. The security of information gathered during an
investigation is the responsibility of the Lead Investigator. On completion of the
investigation, responsibility for security of information gathered is to be transferred to the
SFSO.
200.120.C.5
OSI (RAF) Form Completion. The additional notes annotated to the OSI
(RAF) Form Completion guide are to be used by the Lead Investigator when completing
the form.
200.120.C.6
Disciplinary Action. If the CO or other appropriate superior authority
attributes the cause of the accident either wholly or in part to negligence on the part of an
individual, either in the air or on the ground, any disciplinary action taken or proposed is
not to be stated within the Report or DASOR and supporting comments. The OSI should
be released as soon as possible after conclusion. Disciplinary action/investigation must
occur outside any Air Safety Investigation process.
OSI (RAF) FORM COMPLETION GUIDE
200.120.C.7

The OSI (RAF) Form consists of six parts:

Part 1 DASOR Reference No / Date of Occurrence.

Part 2 Details of Lead Investigator and OSI Commencement and Completion
Part 3 Personnel Information
Part 4 Analysis (Summary of Investigation and Sequence of Events)
Part 5 Findings (Causal Factors/Contributory Factors/Observations/Effects)
Part 6 Prevention (Event Prevention Strategies/Recommendations)
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Part 1. DASOR Reference No / Date of Occurrence

200.120.C.8
Completion of these fields is mandatory and serves to link the OSI (RAF)
Form to the relevant D-ASOR on ASIMS.
Part 2. Investigator/Investigation Details
200.120.C.9
This information identifies the name of the Lead Investigator of the OSI
and also records the time taken to conduct the OSI.
Part 3. Personnel Information
200.120.C.10 The Lead Investigator is not to refer to personnel by name in the Report.
However, it is important that the rank, role and experience of each individual referred to in
the Report is known in order to inform the investigation process. The Lead Investigator is
to use Part 3 to allocate each person referred to in the Report with a Tag Number which is
then used to refer to this person within the Report. Tag Numbers are to be allocated in
numeric order and are not to be duplicated when allocating Tags to personnel roles in
other fields.
Part 4. Analysis
200.120.C.11 Summary of Investigation. This section is provided for the Lead
Investigator to record a summary of the Investigation. It should include a statement of what
was to be investigated.
Note: When untrained investigator(s) have conducted the investigation the following
statement at the start This investigation has been conducted by individuals who have
not received Human Factor Occurrence Investigation Training.
200.120.C.12 Sequence of Events. The Sequence of Events is to be recorded in a
format that clearly shows a timeline of the events that contributed to the occurrence. This
can be listed in tabular or another appropriate format.
Part 5. Findings
200.120.C.13 Occurrence Cause Factors. The Lead Investigator is to identify the main
cause(s) of the occurrence being investigated. Each factor should be characterised using
the drop down menus and attract a brief written description of the system failure.
Note: When untrained investigator(s) have conducted the investigation the Lead
Investigator should not attempt to characterise the cause using the drop down menus as
this function is only to be performed by a trained Occurrence Investigator.
200.120.C.14 Contributory Factors and Amplification. The Lead Investigator is to
identify the contributing factors that contributed to the system failure(s). Contributory
factors inform the convening authority of why the incident/occurrence occurred. The
contributory factors are to be listed in order of influence. Each contributory factor,
characterised using the drop down menus, has to be supported by an Amplification
Statement that describes clearly and specifically how the selected factor contributed to the
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occurrence. Each Contributory Factor may be followed by a recommendation in Part 6. To

that end each Amplification Statement is to be given a unique serial number which is to be
used in Part 6 so that all recommendations can be referred back to an Amplification
Statement.
Note: When untrained investigator(s) have conducted the investigation, the Lead
Investigator should not attempt to characterise the cause using the drop down menus as
this function is only to be performed by a trained Occurrence Investigator.
200.120.C.15 Observations. This section is for completion by the Lead Investigator in
order to formally report an observation(s) made in the course of the investigation, which
although not part of the event or system failure being investigated needs to be highlighted
to the organisation for consideration of further action.
200.120.C.16 Effects. This section allows the investigator to record the outcome and
subsequent effect of the occurrence.
Part 6. Prevention.
200.120.C.17 Event Prevention Strategies. The purpose of this section is to record the
organizational barriers that were in place, yet failed to prevent the event from occurring.
200.120.C.18 Event Prevention Strategies Recommendations. This section is used
to record the recommendations the Lead Investigator believes will prevent re-occurrence
of the event. The section has three columns. The left column (Serial No) is for recording
a serial number (1, 2, 3, etc.) so that recommendation is easier to refer to it. The middle
column (Contributing Factor(s) and observations is used to record the serial number that
was allocated to the contributory factor in Part 5. This is important as it indicates which
contributory factors are being addressed by which recommendation. The right hand
column is used to record the proposed recommendation to prevent reoccurrence.
OCCURRENCE REVIEW GROUP REQUIREMENT
200.120.C.19 An ORG is not to be convened for any investigation undertaken by
untrained investigators. The information recorded on the OSI(RAF) Form is to be uploaded
on ASIMS to the relevant D-ASOR and submitted to the DDH Review group iaw MAA and
DDH policy.

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ANNEX D TO
ORDER 200.120

TERMS OF REFERENCE OCCURRENCE REVIEW GROUP (ORG)

200.120.E.1
a.

General Responsibilities. The ORG is responsible for:

Reviewing the content of OSI (RAF) Form.

b.
Ensuring that the Form correctly identifies, where practicable, the root cause(s)
of the occurrence being investigated.
c.
Reviewing the proposed recommendation(s) to ensure they are achievable
(either by the Stn or higher authority) and will help mitigate the likelihood of
reoccurrence. In addition the ORG may identify any additional recommendations
required.
d.
Determining the culpability of individual(s)/organisation involved in the
occurrence by application of the RAF Just Culture policy.
200.120.E.2
Chairperson Responsibilities. In addition to the responsibilities above
the individual nominated as the Chairperson of the ORG is responsible for:
a.
Ensuring that all ORG members and all other personnel attending the ORG
respect the confidentiality responsibilities of the ORG.
b.
Ensure that sections 1 to 4, and 5 (if required) of the ORG Record of Decisions
and Comments form, at Annex F, are completed and the form returned to the SEMSCo
within two working days of completion of the ORG.
c.
Determine if the OSI needs to be brought to the attention of the DDH or
nominated deputy prior to the OSI being presented at the DH Review Group.
d.
Where culpability is determined, details are to be provided to the relevant Line
and Organisation Management only when the OSI has been closed by the DH Review
Group.
200.120.E.3
Training and Competency Requirements. The competencies required
to undertake the duties of an ORG member are:
a.

Flight Safety|Human Factors Foundation Training|Joint

b.
Flight Safety|Error Management Foundation Training|Joint or Flight Safety|Error
Management Foundation Training|RAF.
c.
Flight Safety|Occurrence Review Group(ORG)|Joint. Individuals who hold
Flight Safety|Occurrence Review Group(ORG)|RAF may sit on ORGs until their Unit
receives DAEMS rollout.
In addition the individual should observe at least one ORG prior to being deemed
competent by the SEMSO.

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AP3207
ANNEX E TO
ORDER 200.120

OCCURRENCE REVIEW GROUP RECORD OF DECISIONS AND COMMENTS

Section 1 ORG Particulars

DASOR Reference No:
Event:
Date of ORG:
ORG Chairperson:
ORG Members:
ORG Members under training:
ORG Assistants:

Section 2 Review of OSI (RAF) Form

The investigation has established the root cause of the event:

Yes:
No:

If No, give brief summary of action taken:

All the causal/contributory factors have been identified:

Yes:
No:

Yes:
No:

If No, give brief summary of action taken:

The recommendations address all the causal/contributory factors:

If No, give brief summary of action taken:

Section 3 Review of Recommendation(s)

Ser
No

Record original OSI(RAF) Form recommendation in this box.

Yes: No:

Recommendation Endorsed by ORG.

If No please give brief explanation of why and details of any other action(s) taken:
1
Suggested Recommendation Owner:
(for DDH Review Group allocation)
Suggested Recommendation Target Date:
(for DDH Review Group allocation)
Priority Assessment 12 : High/Medium/Low

12

A Priority Assessment by ORG as to whether the causal factor resulting in the recommendation represents a High, Medium or Low
Flight Safety risk.

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AP3207
Record original OSI(RAF) Form recommendation in this box.
Yes: No:

Recommendation Endorsed by ORG.

If No please give brief explanation of why and details of any other action(s) taken:
2

Suggested Recommendation Owner:

(for DDH Review Group allocation)
Suggested Recommendation Target Date:
(for DDH Review Group allocation)
Priority Assessment: High/Medium/Low

Section 3a - Additional Recommendations Identified 13

Ser
No

Additional recommendations in this box.

Suggested Recommendation Owner:

(for DDH Review Group allocation)
3
Suggested Recommendation Target Date:
(for DDH Review Group allocation)
Priority Assessment: High/Medium/Low
Additional recommendations in this box.

Suggested Recommendation Owner:

(for DDH Review Group allocation)
4
Suggested Recommendation Target Date:
(for DDH Review Group allocation)
Priority Assessment: High/Medium/Low

Section 4 - Application of RAF Just Culture Policy

Section 4a. Attributed Behaviours
List the Behavioural Type(s) indentified from Chart 1 of the RAF FAiR Tool for each individual involved in the
occurrence.

Is there concern about the culpability of any individual.

*If Yes Section 4b is to be completed.

13

Serial Nos of Recommendations to follow numerically between Section 3 and Section 3a.

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Yes: *

No:

AP3207

Section 4b Determination of Culpability

Using the latest issue of the RAF FAiR Tool, has a level of culpability been determined on any individual (s)
involved in the occurrence
No:
Yes:
Have the Substitution, Routine and Proportionality Tests been applied?

No:

Yes:

Is further action recommended against either an individual(s) or Organisation:

No:

Yes:

Section 5 - ORG Chairperson Comment

1. Comment:

2. Where a level of culpability has been determined iaw the principles of the RAF Just Culture policy, this
determination is to be sent to the Line Manager(s) of the Individual(s) or Organisation(s) concerned via the
DH Review Group. The DH Review Group has been informed of the following ORG decision for each
Individual(s) or Organisation(s) concerned:
No Action Recommended:
Administrative/Disciplinary Action Recommended:
Other : (give details)
3. Form passed to SEMSO (see note) Yes: No:
Note: ORG Forms should only be sent to the SEMSO ahead of the DDH Review Group if the ORG Chairman believes there is a
sensitivity in any of the recommendations or further action recommended.

Rank

Name

Post
ORG Chairperson

Date

Notes:
1.
Once complete, this form is to be attached to the relevant D-ASOR with the OSI(RAF) Form. If
additional comment is required, this is to be recorded using the D-ASOR comment box.
2.

Recommendations are to be managed through the DDH Review Group iaw MAA MRP RA1410.

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200.125
JOINT INVESTIGATIONS

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200.125

JOINT INVESTIGATIONS

200.125.1
Lead Service for Investigations.
Where the occurrence being
investigated (other than an MAA SI) involves personnel or equipment of both the RAF and
another Service, and can best be investigated by a single panel comprising members of
each Service concerned, the investigation is to be initiated by the operating authority of the
aircraft, system or service concerned in the accident.
200.125.2
Composition of Investigative Panels. The other Service(s) will be
consulted to determine the constitution and terms of reference of the investigative panel.
Should there be disagreement as to whether one panel can investigate the case
adequately, or which Service should lead the investigation, then the RAF authority
concerned is to proceed independently. Normally the lead of the panel should be
appointed from the same Service as the operating authority of the aircraft, system or
service concerned in the occurrence.
200.125.3
Separate Service Report. Each Service concerned should be
represented on the panel. Should there be a disagreement, any individual who sits as a
member of an investigative team convened by another Service is entitled, if there is
disagreement, to make a separate report. Such a report is to be forwarded, with the
proceedings, to the lead Service and the individuals ODH safety element. Copies of the
proceedings, including any separate report, are to be forwarded by the corresponding RAF
ODH to IFS (RAF Flt Safety) for transmission to the other Service concerned.
200.125.4
JOINT SERVICE INQUIRY
Where there is a Joint MOD interest in an
accident or incident requiring formal MAA investigation, the convening and composition of
the SI will be decided by the MAA, usually on the basis of major interest or involvement.
200.125.5
RAF/NATO COMBINED INQUIRY NATO involvement in an accident or
serious incident to aircraft, equipment, or personnel of another NATO force may be subject
to a NATO combined investigation under the terms of STANAG 3531. Details of the
procedures to be applied are at Section 200.145. Normally, a NATO combined
investigation should precede any associated national investigation.
200.125.6

RAF/CIVIL PARALLEL INQUIRY UK

200.125.7
Convening of Non-MAA SI Unit-Level Investigation. Investigations into
occurrences involving both RAF and civil interests in the UK can be investigated
separately both by the military and civil authorities. Ordinarily, the MAA will convene an SI
in these instances of potential public scrutiny. However, an RAF formal investigation is
always to be convened when a civil investigation into a combined RAF and civil
occurrence is being held absent an MAA SI. The terms of reference of such investigative
panel to investigate a combined occurrence are to be referred to IFS (RAF Flight Safety)
before promulgation.
200.125.8
Combined Accidents Regulations. Civil investigations into combined
military and civil occurrences are conducted in accordance with the Investigation of Air
Accidents and Incidents (Civil) Regulations 1998 Investigation of Military Air Accidents at
Civil Aerodromes Regulations 2005. These regulations are issued under the joint powers
of the Secretary of State for Defence and the Secretary of State for Transport and are
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hereinafter referred to as the Combined Accidents Regulations. It is usual for the AAIB
Chief Inspector of Air Accidents to initiate a request for a directive from the Secretaries of
State for Defence and for Transport that an investigation be held under these regulations.
However, if it appears to the Service formation concerned that UK civil aviation interests
are, or may be, concerned in an accident to RAF aircraft or that RAF interests are, or may
be, concerned in an accident involving civil aircraft, IFS (RAF Flt Safety) (and 1 Gp-BM-Spt
Occurrences as appropriate) is to be consulted immediately and nothing is to be done
which might prejudice an inquiry called by the MAA or under the Combined Accidents
Regulations. Examples of the types of occurrences covered by the Combined Accidents
Regulations are:
a.

A collision between an RAF aircraft and a civil aircraft.

b.
An occurrence involving an RAF aircraft approaching, landing at, taking-off or
departing from a civil airfield.
c.
An occurrence involving a civil aircraft approaching, landing at, taking-off, or
departing from an RAF airfield.
d.
An incident or airmiss in general circumstances, as given in sub-paras a, b or c,
that could have resulted in an accident.
e.
An occurrence occurring in such circumstances that the Department of
Transport may be concerned or interested in the circumstances or causes.
200.125.9
Preliminary Investigation. Before the joint decision of the Secretaries of
State for Defence and for Transport is made, the DG MAA and/or the CAA may wish an
inspector on his/their staff to make preliminary inquiries (or a field investigation) at a
Service establishment in order to ascertain to what extent the Service is involved and to
obtain details of the circumstances. The inspector should be allowed as full access as
possible and should be given a liaison officer (appointed by the station concerned) during
this preliminary investigation; any question of access to classified material should be
cleared through the executive branch concerned. Once an investigation under the
Combined Accidents Regulations has been authorised, the decision will be notified to
command and group headquarters and the station concerned by the IFS (RAF Flt Safety)
on direction by, or in consultation with, the MAA.
200.125.10
Conduct of a Formal MAA/CAA Investigation. If the Secretaries of
State for Defence and for Transport decide jointly that a particular occurrence should be
investigated under the Combined Accidents Regulations, the DG MAA and the CAA will
appoint an inspector(s) to conduct the investigation and may invite IFS (RAF Flt Safety) to
appoint a liaison officer to be in attendance. This officer should not have been directly
associated with the examination or testing of individuals concerned in the accident. He is
under the remit of and obligated to the DG MAA and the CAA, and not to the ODH/IFS
(RAF Flt Safety). It is emphasised that the liaison duties do not make the investigation
joint. It remains an MAA/CAA investigation and can in no way be regarded as an RAF
formal investigation. Nor must this investigation be confused with the technical
investigations undertaken from time to time by the MAAAIB into certain Service accidents
at the request of DG MAA in conjunction with an MAA SI.

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200.125.11
Responsibilities of RAF Liaison Officer. The responsibilities of the
Service liaison officer appointed in attendance to a joint MAA/CAA investigation will be
detailed by DG MAA and the CAA at the time. In general terms, his responsibilities are:
a.
To arrange access for the inspectors to Service installations, Service witnesses
and evidence contained on Service installation.
b.
To inform DG MAA of any special development or flight safety hazard revealed
by the investigation after consultation with the inspector.
c.
To brief Service witnesses on the civil procedure for taking evidence and the
terms of the Combined Accidents Regulations and, with the witnesss agreement, to
listen to this evidence in order to ensure that Service witnesses are given every
opportunity to put their own points of view, accurately expressed in relation to their
own part in the occurrence.
200.125.12
Disciplinary Matters. Matters affecting the discipline or internal
administration of any RAF personnel may be passed to the RAF by the DG MAA/CAA
investigation. In all cases, Defence Legal Services must be consulted by the RAF
command authority for advice regarding legal aspects of the investigation.
200.125.13

RAF/CIVIL (OR NON-NATO MILITARY) INQUIRY OVERSEAS

200.125.14
If overseas the RAF should become involved in an accident concerning a
civil or non-NATO aircraft, an MAA SI will be convened. IFS (RAF Flt Safety) is to be
consulted immediately about RAF representation at an associated inquiry convened by the
foreign government concerned, who will in turn consult the DG MAA on further action.

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200.130
RAF AVIATION ERROR MANAGEMENT SYSTEM

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200.130 RAF AVIATION ERROR MANAGEMENT SYSTEM (RAF AEMS)

200.130.1
Aviation presents a complex environment that is subject to HF related errors
and unhealthy organisational norms which can lead to undesired outcomes. The RAF
Aviation Error Management System (RAF AEMS) is the RAF element of the pan-defence
Defence Aviation Error Management System (DAEMS) project. It plays a crucial role in
the management of risk associated with HF related error, both individual and
organisational. It enables us to gather information, via the Air Safety Information System
(ASIMS), analyse how we do things, consider how we might change our behaviour and,
more importantly, our culture to enhance Air Safety whilst maintaining our operational
focus. Through RAF AEMS we will gain an improved understanding of the RAFs Error
Iceberg and how our people are likely to perform in relation to the organization and
environment within which they work, and so we will be able to set them up to do it right;
providing them with safeguards to manage errors when they happen.
200.130.2
RAF AEMS will retain a common look and feel across the RAF (and
Defence) and will provide the essential knowledge, tools, framework and language to
enable the organisation to understand and communicate the types of errors that are
occurring, and manage the associated risk at an appropriate level. Through effective
investigative and analysis processes RAF AEMS will provide high quality, reliable
information that will facilitate decision making on the application of scarce resource. Most
importantly, it will enable us to apply HF knowledge in a practical way throughout the
support chain to enhance flight safety. However, as the success of the system is
dependent on our people reporting errors, it is important to understand that RAF AEMS is
not limited to the individual engineer, aircrew, air-trafficer or support personnel. It includes
strategic decisions made by senior managers, organizational cultures, sqn norms, the
effect of change initiatives, badly written technical manuals, inadequate resources, poor
planning, insufficient training, austere environmental conditions: in fact every single layer
of the organisation and anything or anyone who can directly or indirectly impact our ability
to safely and legally operate our aircraft.
200.130.3
RAF AEMS is underpinned by the RAF Just Culture policy 1 that aims to
provide an environment under which an open and honest reporting system can thrive. It
will deliver a working environment where individuals are encouraged to contribute proactively to providing essential safety related information and where they should be
commended for owning up to mistakes in their honest endeavour to do their best. It should
promote a sense that they will be treated fairly and with complete integrity while we
investigate why mistakes have been made, in our collective efforts to get things right next
time.
200.130.4
Defence Aviation Error Management (DAEMS) Programme. The Defence
Aviation Error Management (DAEMS) programme aims to implement effective RAF AEMS
across the UK Defence Aviation community. The DAEMS Project is an evolution and
development of existing aviation safety reporting and investigation processes, which it
seeks to enhance, harmonise, and bind together the 3 error management components of
Just Culture, Human Factors (HF) Awareness and Information Management & Exploitation
1

AP3207, Order 200.135

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to create an effective safety improvement programme by identifying, mitigating and

controlling HF related errors and risk. The Pan-Defence programme that is due to
complete in Apr 15 will also ensure that a sustainable package of specialist training is
provided beyond the programme completion date.
200.130.5
Applicability. This order is applicable to those stations/units 2 that have had
RAF AEMS introduced as part of the MAA DAEMS programme. Additional RAF
Stations/Units will have RAF AEMS rolled out over the period of the contract to a schedule
directed by the MAA following consultation with Command Staffs. In addition, this order
remains applicable to those stns that were subject to the original MEMS rollout within the
A4 community 3 until they receive DAEMS rollout.
200.130.6
RAF AEMS Process. There are 4 distinct phases to the management of
error investigation within AEMS.
a.
Reporting Phase. High quality reporting is the critical element of a
successful RAF AEMS 4 .
b.
Investigation Phase. A proportion of reported errors will require formal
investigation, the SEMSO, or his nominated deputy, in consultation SEMSCo will
decide which warrant closer consideration. To assist this process trigger levels
should be set locally so that it is broadly understood what types of events will be
investigated 5 .
c.
Decide and Respond Phase. The Respond phase is led by the
Occurrence Review Group (ORG) and provides the opportunity to formally review,
and consider the quality of, the findings of an investigation, and to ensure proper
management of the lessons learned.
d.
Review Phase. By extension, the Respond phase also implies the need to
review data periodically and, furthermore, to hasten or monitor outstanding
recommendations from earlier investigations.
The flow of a report through the system is demonstrated in the flowchart at Annex A. In
addition to the above feedback to reporters is a vital step in the AEMS. The feedback of
information to the reporter will ensure that individuals are empowered to support the
system and will promote the continued use of reporting events.
Responsiblilities
200.130.7
Station Error Management System Owner (SEMSO). Each Stn Cdr/DDH
will assume the role of Station Error Management System Owner (SEMSO). The TORs, at
Annex A, include:
a.

Establish a corporate memory as detailed in RA1130.

Includes those Stations/Units within the AOR of the listed Station/Unit that have been identified as being within the
Air Safety 4-World environment.
3
The RAF Maintenance Error Management System (MEMS) was rollout to the A4 community included the following
RAF Stns: Benson, Brize Norton, Coningsby, Leuchars, Lossiemouth, Marham, Odiham, RAFAT and Waddington.
4
AP3207 Order 200.105 details the reporting procedures.
5
AP3207 Order 200.120 details the reporting procedures.

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b.
Establish a reporting mechanism in support of the ASMS as detailed in
RA1410 and the Manual of Air Safety Section 3 - reporting and investigation of
occurrences.
c.
Establish Hazard Identification & Analysis processes as detailed in RA 1210
Para 9a.
200.130.8
Station Error Management System Coordinator (SEMSCo). Each
SEMSO should establish a post(s) within their AOR to manage the RAF AEMS on a day to
day basis. The SEMSCo, TORs at Annex C, is responsible for:
a.
Providing a visible presence of the RAF AEMS in operation and encouraging
participation in the RAF AEMS by use of coaching and mentoring.
b.
The staffing of RAF AEMS(hard copy and ASIMS derived) reports using the
RAF AEMSReport Management Form at Annex D.
c.
Data monitoring (rates and quality of reports) and information management
and exploitation including the collection of cultural stats at Annex E.
c.
The coordination and assurance of Occurrence Safety Investigations and
Occurrence Review Group (ORG) including the maintenance of the training logs at
Annex F for OIs and ORG members.
d.

To action feedback on RAF AEMSreports and investigations.

g.
To be responsible for suitable and effective communications related to the
EMS within the EMSO AOR.
j.

To be an advisor to the DDH risk management function.

200.130.8
Local Error Management System Coordinator (LEMSCo). The SEMSO
should establish posts within their AOR to manage RAF AEMSat a local level. The AOR
of these posts will depend on the size and location of each unit. They will also provide a
consistent source of support and guidance to personnel and create the necessary pull for
an EMS to be successful at a local level. The LEMSCo, TORs at Annex G, is responsible
for:
a.

Providing support, advice and guidance within their respective AOR.

c.
Ensuring RAF AEMSnotice boards are kept up to date and contain relevant
material targeted at each group within the AOR.
d.
Handling non-confidential RAF AEMSreports and providing feedback to the
Reporters.

Annexes:
A.

RAF Aviation Error Management System Flowchart

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AP3207

B.
C.
D.
E.
F.

Terms of Reference Stn Error Mgt System Owner (SEMSO)

Terms of Reference Stn Error Management System Coordinator (SEMSCo)
Terms of Reference Local Error Management System Coordinator (LEMSCo)
Terms of Reference Regional Error Management System Coordinator (REMSCo)
Terms of Reference Regional Occurrence Investigator (ROI)

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ANNEX A TO
ORDER 200.130
RAF Aviation Error Management System Reporting and Investigation Process Flowchart
Occurrence, Near-miss, Hazard, Observation to
be reported
The person wishing to report can choose to raise a DASOR
into ASIMS or, if preferred, an AEMS Report Form.
If the Reporter is unsure
whether the issue is related
to Air Safety an AEMS
Report Form should be
raised

Raise D-ASOR

Raise AEMS Report

Confidential

Feedback to
Originator
Occurrence Manager(s)
(SFSO/SEMSCO)
Non-Air Safety DASOR to be
deleted from ASIMS
Report managed through
Extant Processes (H&S etc)

Feedback to
Originator

LEMSCO

Clarification of Report

Clarification

Local Attention,
Action

All Air Safety related AEMS

Reports to be raised as DASOR

Feedback to
Originator
Identify Causal and
Contributory factors and trend
on ASIMS

Occurrence Safety
Investigation
Required?
Y

Pro-active Investigation
(Through trending of reports received)

Form Investigation Team

Carry Out OSI

Complete OSI (RAF) Form

Form and Undertake ORG

Manage Recommendations &

further comments on ASIMS

Feedback to
Originator

DDH/SEMSO/ Hd of Establishment
or Aerodrome Operator
Review Group

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ANNEX B TO
ORDER 200.130
TERMS OF REFERENCE STATION AVIATION ERROR MANAGEMENT SYSTEM
OWNER (SEMSO)
200.130.B.1 Overall Responsibility. As the SEMSO 1 you are responsible to the SDH
through the ODH for the effective governance of the RAF Aviation Error Management
System (AEMS) on your station and other areas within your AOR.
200.130.B.2 General Responsibilities. General responsibilities are:
a.
To ensure the appropriate selection, appointment, training and competency of
personnel who fulfil management roles within AEMS.
b.
To ensure that Error Management System adopted within the AOR is conducted iaw
HQ Air Command policy and adequately resourced.
c.

To convene Occurrence Safety Investigations 2 .

d. To establish Safety Performance Indicators 3 to monitor the effectiveness of the

AEMS.
e. To ensure suitable and sufficient communication and feedback is established to
promote and sustain the AEMS.
These general responsibilities may be delegated to an appropriately trained individual
within the AOR.
200.130.B.3 Specific Responsibilities. Specific responsibilities are:
a.
To be the custodian, within your AOR for the implementation and consistent
application of the RAF Just Culture policy.
b.
Authorise the appointment of personnel as to be members of an Occurrence Review
Group (ORG).
200.130.B.4 Training/Competency Requirements. The Training and competencies
required to undertake the duties of SEMSO are:
a.

RAF Human Factors Foundation training.

b.

RAF Error Management Foundation training.

c.

Occurrence Review Group training.

Station Error Management System Owner. This position is to be filled by the Stn Cdr/DDH/Head of Establishment/((Aerodrome
Operator) to be ratified by the MAA).
2
IAW AP3207 Order 200.120.
3
Manual of Air Safety Chapter 2, Section 4

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ANNEX C TO
ORDER 200.130
TERMS OF REFERENCE STATION ERROR MANAGEMENT SYSTEM
COORDINATOR (SEMSCO)
200.130.C.1. Overall Responsibility. You are responsible to the Station Error
Management System Owner (SEMSO) and nominated deputies for the effective
monitoring, operation and administration of the RAF Aviation Error Management System
(AEMS).
200.130.C.2 General Responsibilities. Responsibilities include:
a.

Advising personnel within your AOR on any aspect of the AEMS.

b.

Acting as a focal point, within your AOR, for all issues relating to the AEMS.

c.
Regular liaison with the Station AEMS Champions and Local Error Management
System Coordinators (LEMSCos).
d.
Regular liaison with the SFSO, Dep SEMSCo(s) and LEMSCo(s) to review the
effectiveness of the AEMS within AORS and to communicate good practice.
e.
Giving support to the LEMSCos in publicising and promoting the AEMS across the
AOR.
f.
The visiting of units/sections within your AOR to give a visible presence to the
AEMS in operation and to encourage participation in the AEMS by use of coaching and
mentoring.
g.
Advising and guiding the SEMSO, nominated deputies, ORG members and others
on the application of the RAF Just Culture policy, seeking support and guidance from
Group HQ and RAF Flight Safety Staffs, as required.
h.
The development, compilation and monitoring of KPIs, information and statistics as
required by the SEMSO, nominated deputies, Group HQ and Command Staffs.
i.
Maintaining close and regular liaison with other SEMSCos, Regional AEMS
Coordinator (REMSCO), Group HQ and RAF Flight Safety Staffs.
j.
The monitoring of the reporting rates and types of AEMS Reports being submitted,
bringing to the attention of the SEMSO or nominated deputy any significant disparity in
AEMS reporting rates across the AOR.
k.
Notifying the REMSCO of when an Occurrence Safety Investigation (OSI) Peer
Review Group is taking place.
l.
To compile the Cultural Data Stats return 1 monthly and send to RAF Flight Safety
FS AEMS and the REMSCO by the tenth day of the following month.
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m.
To identify Air Safety trends to local management for consideration of further action
by regular and routine analysis of the data and information captured into ASIMS.
n.
To raise and maintain a Occurrence Investigator and Occurrence Review Group
Member Training and Activity Log 2 for each Occurrence Investigator and ORG member
within the AOR. A copy of the completed Log is to be handed to the person on their
permanent or temporary (OOA Det) from the stn/unit.
o.
To review six monthly the individual competencies and currencies of Occurrence
Investigators and ORG members within the AOR to ensure that all are current and
competent to undertake the required duty.
p.
To convene and chair a Station OSI Peer Review Group at least every three
months. The Peer Review Group is to review a minimum of one OSI to identify good and
bad practice for the SEMSCO to communicate to other OIs within the AOR. A minimum of
three OIs are to attend a Peer Review Group.
200.130.C.3 Staffing of Reports. Key responsibilities are:
a.
To review the content of all AEMS Reports 3 received and assess the actions taken
(if any) to ensure that all air safety implications within the report have been identified and
that any mitigation(s) planned/instigated will be effective and sustainable.
b.
To instigate, if required, further action(s) liaising with local management and the
LEMSCO.
c.
To ensure that all AEMS Reports received that are assessed as air safety related
are raised as a DASOR and staffed iaw MAA ASIMS policy and procedures.
d.
To ensure that all AEMS Reports received that are assessed as non-air safety
related are forwarded to the appropriate SME/AOR for further staffing and that the reporter
is informed accordingly. Non-air safety related AEMS Reports are not to be raised as a
DASOR.
e.
To ensure that all Confidential AEMS Reports received are administered so as not
to identify the reporter to any other person unless prior permission to do so has been
obtained from the reporter.
f.
Ensure that a Form 002 4 is raised and compiled for all RAF AEMS Reports Form
001 received 5 .
g.
To ensure that feedback detailing the follow-up action(s) taken is communicated to
the reporter at the earliest opportunity but no more than seven working days from receipt
of the AEMS Report.

AP3207 Order 200.130, Appendix 2 to Annex C.

AP3207 Order 200.105, Annex B.
4
AP3207 Order 200.130, Appendix 3 to Annex C.
5
A locally developed spreadsheet may be used instead of Form 002 providing that the spreadsheet fulfils the same requirements and is
authorised for use by the SEMSO.
3

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i.
To assess the need to inform the SEMSO, nominated deputy or senior line
management of any AEMS Report received. Consideration should be given to the
possibility of Risk to Life, personal injury, environmental damage, operational capability,
reputation and financial cost. Where there is concern or doubt regarding possible risk,
further advice should be sought from local safety management
j.
To liaise with the Occurrence Manager(s) and have knowledge of reports raised
directly as a DASOR which require a staffing input from the SEMSCO.
200.130.C.4 Occurrence Safety Investigations. Key responsibilities are:
a.
Ensuring that all personnel who satisfy the training and competency requirements
for an Occurrence Investigator are awarded the relevant competence on JPA.
b.
With assistance from LEMSCos the selection of appropriate personnel to undertake
an OSI, including the nomination of a Lead Investigator.
c.
If required, request the support of an Occurrence Investigator from the Regional
AEMS Team via the Regional AEMS Team Coordinator (REMSCO).
d.
To advise, guide and give support to Occurrence Investigators during the course of
an investigation.
e.
Prior to an investigation being submitted to an ORG, to review the investigation to
ensure that the Investigator(s) has met the requirements of the Occurrence Investigator
ToRs 6 and that the investigation has been undertaken and OSI(RAF) Form compiled iaw
current HQ Air policy 7 and guidance which is to include a review for consistency, accuracy,
completeness and anonymity.
f.
On completion of the OSI to attach the completed OSI(RAF) Form 8 and ORG RoD
9
Form to the associated DASOR.
g.
To review weekly all ongoing investigations to ensure that the investigation is
progressing satisfactorily and give direction to the Occurrence Investigators when
considered required.
200.130.C.5 Occurrence Review Group. Key responsibilities are:
a.

To convene an ORG within two weeks of receiving a completed OSI(RAF) Form.

b.
To ensure that personnel selected to be members of an ORG are authorised to do
so iaw HQ Air Command AEMS Policy 10 .
c.
When considered required to advise members of an ORG on all aspects of the
AEMS and the RAF Just Culture Policy 11 , including application of the FAiR tool.

AP3207 Order 200.120 Annex B.

AP3207 Order 200.120.
8
AP3207 Order 200.120 Annex A.
9
AP3207 Order 200.120 Annex E.
10
AP3207 Order 200.130.
11
AP3207 Order 200.135.
7

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d.

That the ORG RoD form is completed and Section 5 signed off by the ORG
Chairperson within one week from completion of the ORG
e.
On completion of the ORG all data and information recorded on the OSI(RAF) Form
and those recommendations that have been accepted/amended/added by the ORG are
entered into the relevant sections of the associated DASOR and subsequently managed
through the DDH Review Group iaw MAA MRP RA1410.
f.
To ensure that all personnel who are trained to participate as a member of an ORG
are awarded the relevant competence on JPA.
g.
To inform the REMSCO when an ORG is being convened, where possible giving
five working days notice.
200.130.C.6 Training/Competency Requirements. Training courses to be
completed/required prior to taking post are:
Mandatory
a.

RAF Human Factors Foundation Course.

b.

RAF Error Management Foundation Course.

c.

ASIMS DLP Training Package (All Role Groups).

Essential (To be completed within 3 months of taking up post)

d.

Occurrence Investigator Course.

e.

Occurrence Review Group Course.

f.

Effective Error Management System Course.

Highly Desirable
g.

Risk Management Training.

h.

Safety Management System Training.

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Occurrence Safety Inves

Age of Reporting

Reporting Culture

APPENDIX 3
TO ANNEX C OF ORDER 200.130

RAF TBA

Jan

Feb

The number of AEMS/QI/CI/III

Reports received/sighted in
Month (see Comment)

12

The number of Confidential

Reports received in the month
(See Comment)

The number of Anonymous

Reports received in the month
(See Comment)

The number of Air Safety

Related AEMS/QI/CI/III Reports
received in Month for entry
into ASIMS

The number of of Haz/Obs

Reports Entered Directly into
ASIMS by the Reporter

14

22

The total No of Air Safety

Related Reports raised in
Month

13

17

30

15

10

The number of pro-active

Occurrence Safety
Investigations instigated

The number of re-active

Occurrence Safety
Investigations instigated

The number of Air Safety

reports that were assessed as
1st Age.
The number of Air Safety
reports that were assessed as
2nd Age
The number of Air Safety
reports that were assessed as
3rd Age

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Total

STAFF IN CONFIDENCE (when complete)

Appendix 2 to Annex C 200.130

OCCURRENCE INVESTIGATOR AND OCCURRENCE REVIEW GROUP MEMBER

TRAINING AND ACTIVITY LOG
Rank (in pencil)

Name

Service No

Training Courses
Course Name
(a)

SEMSCO Authorisation
Course No
(b)

Date Passed
(c)

Verification
(d)

Q-OI

Q-ORG

Signature
Date
Signature
Date
Occurrence Safety Investigations (OSI) Record
Date OSI
Commenced
(a)

Date OSI
Completed
(b)

DASOR No
(c)

Stn/Unit/Section
(d)

Lead OI
Y/N
(e)

No of OI
in Team
(f)

Duration
Manhrs/day
(g)

Verification
(h)

Notes
(i)

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STAFF IN CONFIDENCE (when complete)

Appendix 2 to Annex C 200.130

Rank (in pencil)

Name

Service No

OSI Record (continued)

Date OSI
Commenced
(a)

Date OSI
Completed
(b)

DASOR No
(c)

Stn/Unit/Section
(d)

Lead OI
Y/N
(e)

No of OI
in Team
(f)

Duration
Manhrs/day
(g)

Verification
(h)

Notes
(i)

Occurrence Review Group Record

Date of ORG
(a)

DASOR/OSI Ser No
(b)

Chairperson
Y/N
(c)

Verification

(d)

Date of ORG
(a)

DASOR/OSI Ser No
(b)

Chairperson
Y/N
(c)

Verification

(d)

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STAFF IN CONFIDENCE (when complete)

Appendix 2 to Annex C 200.130

GUIDANCE NOTES

Compilation of OSI Record

Col a

DD/MM/YYYY that the Occurrence Investigator received commenced the OSI.

Col b

DD/MM/YYYY that the OSI (RAF EDA) was completed and handed to the SEMSCO.

Col c

Ser No of the DASOR to which the OSI relates.

Col d

Stn/Unit/Section is the location at which the OSI is being conducted.

Col e

Enter Y if nominated as the Lead Investigator for the OSI.

Col f

Number of Occurrence Investigators undertaking the OSI.

Col g
Number of man hours/days actually expended by the OI on any activity relating directly to the OSI between the period
identified at column a and Column b.
Col h

SEMSCo to sign/date to verify activity.

Col i

For use of SEMSCO for general note/comments as required.

ORG Record
Col a

DD/MMM/YYYY that the ORG commenced.

Col b

Ser No of the DASOR to which the ORG relates.

Col c

If nominated as the Chairperson of the ORG enter Y

Col d

SEMSCo to sign/date to verify activity.

RAF Flight Safety Local Form 006 Issue 1

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AEMS

Appendix 2 to Annex C 200.130

AEMS Report Form Ser No:

Block 1 (LEMSCO Use Only)

Air Safety Issue:

Yes

If Yes:

Age of Report

Perceived Severity 1 :

No

A-High

1st Age

2nd Age

B - Medium

3rd Age

C-Low

D-Negligible

Brief Title:

Action /
Comment

(Mandatory)
AEMS Report attached
and sent/copied to
SEMSCo:

Rank:

Name

Date:

Signature:

Block 2 (SEMSCO Use Only)

Air Safety Issue

Yes

No

DASOR Ser No:

(If Yes DASOR is a Mandatory Requirement)

Management Action taken:

Not Air Safety
CI

QA

H&S

Other

(details:

Additional Comment:
Feed back given to
Report Originator via
LEMSCo
All Actions Completed

Yes

Rank:

Name

Date:

Signature

Subjective Assessment by the person submitting the AEMS Report (Categories align with ASIMS requirement)

RAF Flight Safety Local Form 002 Issue 4

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ANNEX D TO
ORDER 200.130
TERMS OF REFERENCE LOCAL ERROR MANAGEMENT SYSTEM COORDINATOR
(LEMSCo)
200.130.D.1 Overall Responsibility. You are responsible to the Station Error
Management System Owner (SEMSO) thru the Station Error Management System
Coordinator (SEMSCo) for providing support to the Aviation Error Management System
(AEMS) within your Section/Squadron/Unit.
200.130.D.2 General Responsibilities. Responsibilities include:
a.

Advising personnel within your AOR on any aspect of the AEMS.

b.

Acting as a focal point within your AOR for all issues relating to the AEMS.

c.
Supporting the SEMSCo in the promotion and publicising of the AEMS within your
AOR.
d.
To encourage personnel to participate in the AEMS by coaching and mentoring
personnel as necessary.
e.
Regular liaison with the SEMSCo to review the effectiveness of the AEMS within
AORS and to communicate good/best practice throughout the unit/section.
f.
To ensure that the AEMS information boards are maintained, prominent, easily
accessible and have on them current AEMS information.
g.
To ensure that AEMS Report forms are readily available on the AEMS information
boards and in other locations within your AOR. Ensure that envelopes addressed to the
SEMSCo are readily available for use of personnel wishing to submit a Confidential
AEMS Report.
h.

Provision of an AEMS brief to all new arrivals on the unit/section.

i.
Assisting the SEMSCo in selecting suitable personnel to undertake Occurrence
Investigations.
j.

To be the representative for the unit/section at stn convened AEMS meetings.

d.
Feedback on the follow-up action(s) being taken is to be notified to the reporter at
the earliest opportunity but no more than seven working days from receipt of report.
Additional feedback should be given to the reporter following the completion of any ORG
held corresponding to the report raised or actions taken due to the report are complete.
200.130.D.3 Staffing of Hard Copy AEMS Report Forms. Specific responsibilities:
a.
To receive and read all non-confidential AEMS reports and bring to the attention
of Line Management to decide on appropriate staffing/action. An AEMS report assessed
by the LEMSCo to be a significant risk to air safety is to be brought to the attention of Line

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Management without delay. Any Confidential AEMS Reports received are to be sent
directly to the SEMSCo.
b.
All AEMS reports received are to be copied to the SEMSCo noting local action
taken using RAF Flight Safety Form 002 1 or equivalent spreadsheet.
200.130.D.4 Training and Competency Requirements. Training and competencies
required to undertake the duties of LEMSCo are:
Mandatory
a.

RAF Human Factors Foundation course.

b.

RAF Error Management Foundation course.

Essential (To be completed within 3 months of taking up post)

c.

Effective Error Management System Course.

Highly Desirable
d.

Risk Management Training.

AP3207 Order 200.130 Appendix 1 to Annex C.

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ANNEX E TO
ORDER 200.130
TERMS OF REFERENCE REGIONAL ERROR MANAGEMENT SYSTEM
COORDINATOR
200.130.E.1 Overall Responsibilities. You are responsible to RAF Flight Safety SO2
AEMS for :
a.
Monitoring the implementation of the AEMS to ensure that it is operated in
accordance with HQ Air Command RAF AEMS Policy 1 .
b.
Acting as a focal point for AEMS specialist personnel for information and
advice.
c.
The effective management, coordination and administration of activity being
undertaken by personnel employed as members of the Regional Aviation Error
Management System Team.
d.
Undertaking the specific responsibilities detailed at Appendices 3, 4 or 5, as
applicable.
200.130.E.2 General Responsibilities. Your general responsibilities are:
a.
To bring to the attention of SO2 AEMS any concern you have regarding the
operation of the AEMS policy and procedure.
b.
To develop and maintain regular communication with specialist AEMS
personnel.
c.
To advise, coach and mentor personnel on any topic within the scope of the
AEMS.
d.
To attend Occurrence Review Groups (ORG) and give feedback to the ORG
Chairperson and SEMSCO on the application of ORG procedure and RAF Just
Culture policy. If considered required, feedback is also be given to the SEMSO or
nominated deputy.
e.
To identify and promote good practice to develop consistent application of
AEMS policy and procedures.
f.
To identify bad practice and inform the appropriate AEMS specialist
and, if required, RAF Flight Safety SO2 AEMS.

g.

To participate in Occurrence Safety Investigation Peer Review Groups.

h.

To assist with the development of effective KPIs.

AP 3207 Order 200.130

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i.
To develop, encourage and sustain a common RAF AEMS publicity and
communication strategy between the RAF stations within your AOR.
j.
To ensure, where possible, that RAF AEMS training courses being delivered
are loaded to maximum capacity by coordinating RAF AEMS specialist training
requirements with SEMSCos and REMSCos.
k.
To allocate a Regional Team Occurrence Investigator (ROI) to an
Occurrence Safety Investigation (OSI) when the assistance of an ROI is requested.
l.
Monitor the progress of any OSI to which a Regional Team Investigator has
been allocated to ensure that the OSI is being conducted effectively and in a timely
manner.
m.
To monitor the Reporting Culture using the data from the Monthly Cultural
Stats return 2 raising any concerns with the appropriate AEMS specialist staff.
n.

To represent RAF Flight Safety/SO2 AEMS at safety events.

200.130.E.3 Administrative Responsibilities. Responsibilities are:

a.
To complete and return the Activity and MT Usage proforma 3 monthly to
RAF Flight Safety SO2 AEMS.
b.
Liaise with the RAF Flight Safety Budget Manager wrt the management and
administration of any budget allocated/required.
c.
For the administration and management of MT vehicles provided iaw JSP
800 and local orders.
d.

For the management and control of Government provided Fuel Cards.

Appendices:
1

RAF Flight Safety Local Form 007 Regional AEMS Team Activity Log.

RAF Flight Safety Local Form 008 Regional AEMS Team MT Usage Log.

3.

Specific ToRs - Regional Error Management System Coordinator (Midlands).

4.

Specific ToRs - Regional Error Management System Coordinator (North).

5.

Specific ToRs - Regional Error Management System Coordinator (South)

2
3

AP3207 Order 200.130 Appendix 3 to Annex C.

AP3207 Order 200.130 Appendices 1 and 2 to Annex E.

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APPENDIX 1 TO
ANNEX E TO
ORDER 200.130
REGIONAL AEMS TEAM (North / Midlands / South)* - ACTIVITY LOG
(* Delete as applicable)

Week Commencing

/./.20.....

Activity

Location

DASOR Ser No if applicable

ORG, OI, Peer Review etc

Station/Unit

Personnel
Tasked

Date
Date
Commenced Completed

RAF Flight Safety Local Form 007 Iss 1 dated 31 Aug 12

Edition 8

Duration

Remarks/Comments

(Days)

Sheet No of.

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APPENDIX 2 TO
ANNEX E TO
ORDER 200.130
REGIONAL AEMS TEAM (North / Midlands / South)* - MT USAGE LOG
(* Delete as applicable)

Week Commencing /./.20.

Date

Vehicle Type

Reg No

Destination

Purpose

RAF Flight Safety Local Form 008 Iss 1 dated 31 Aug 12

Edition 8

Miles Run

Remarks/Comments

Sheet No of ..

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APPENDIX 3 TO
ANNEX E TO
ORDER 200.130
TERMS OF REFERENCE REGIONAL ERROR MANAGEMENT SYSTEM
COORDINATOR (Midlands)
200.130.E.3.1. Specific Responsibilities. You are responsible to RAF Flight Safety SO2
AEMS for undertaking the duties detailed at Annex E. RAF Stations and Units in your AOR
are:
a.
RAF Cosford
b.
RAF Coningsby
c.
RAF Cranwell
d.
RAF Marham
e.
RAF Scampton/RAFAT
f.
DHFS Shawbury/RAF Shawbury
g.
SARF Valley (22 Sqn C Flight, SARTU, SARF HQ)
h.
RAF Valley
i.
RAF Waddington including 39 Sqn Creech AFB, USA
j.
RAF Wittering
200.130.E.3.2.
On behalf of RAF Flight Safety SO2 AEMS, be the focal point for the
Southern and Northern REMSCOs for any matter relating to AEMS policy and procedure.
200.130.E.3.3.
Administrative Responsibilities.
To the Inspector of Flight
Safety and the Commanding Officer, RAF Cranwell for the maintenance of discipline and
general administration of all personnel employed as members of the Regional AEMS
Team (Midlands).

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APPENDIX 4 TO
ANNEX E TO
ORDER 200.130
TERMS OF REFERENCE REGIONAL ERROR MANAGEMENT SYSTEM
COORDINATOR (North)
200.130.E.4.1. Specific Responsibilities. You are responsible to RAF Flight Safety SO2
AEMS for undertaking the duties detailed at Annex E. The RAF Stations and Units in your
AOR are:
a.

RAF Boulmer

b.

SAR Leconfield

c.

RAF Leeming

d.

RAF Leuchars

e.

RAF Linton on Ouse

f.

RAF Lossiemouth

g.

RAF Spadeadam

h.

ScATTC (Mil)

200.130.E.4.2.
On behalf of RAF Flight Safety SO2 AEMS, be the focal point for the
Southern and Midlands REMSCos for all matters relating to generic and specialist AEMS
training.
200.130.E.4.3.
Administrative Responsibilities.
To the Inspector of Flight
Safety and the Commanding Officer, RAF Leeming for the maintenance of discipline and
general administration of personnel employed as members of the Regional AEMS Team
(North).

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APPENDIX 5 TO
ANNEX E TO
ORDER 200.130
TERMS OF REFERENCE REGIONAL ERROR MANAGEMENT SYSTEM
COORDINATOR (South)
200.130.E.5.1.1 Specific Responsibilities. You are responsible to RAF Flight Safety SO2
AEMS for undertaking the duties detailed at Annex E. RAF Stations and Units in your AOR
are:
a.

RAF Boscombe Down

b.

RAF Brize Norton

c.

LcATTC (Mil)

d.

RAF Northolt

e.

SAR Chivenor

f.

SAR Wattisham

g.

84 Sqn Cyprus

h.

RAF Benson (only if requested by JHC)

RAF Odiham (only if requested by JHC)

200.130.E.5.2.
On behalf of RAF Flight Safety SO2 AEMS, be the focal point for the
North and Midlands REMSCos for all matters concerning any request for AEMS support
from PJOBS and RAF deployed OOA locations.
200.130.E.5.3.
Administrative Responsibilities.
To the Inspector of Flight
Safety and the Commanding Officer, RAF Halton for the maintenance of discipline and
general administration of personnel employed as members of the Regional AEMS Team
(South).

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ANNEX F TO
ORDER 200.130
TERMS OF REFERENCE REGIONAL OCCURRENCE INVESTIGATOR
200.130.F.1 General Responsibilities. You are responsible to RAF Flight Safety SO2
AEMS for:
a.
Undertaking Occurrence Safety Investigations (OSI) in support of the
RAF AEMS within the Regional Team AOR iaw with RAF policy 1 .
b.
Undertaking Occurrence Safety Investigations outside the AOR as discussed
with your Regional Aviation Error Management System Coordinator (REMSCo) and
agreed by RAF FS SO2 AEMS.
c.

Assisting the REMSCo in undertaking his/her duties.

d.

Providing assistance and advice to Occurrence Review Groups.

e.

Participating in OSI Peer Review Groups.

f.
The production of OSI Summaries for distribution within the AOR and
REMSCos to promote AEMS and communicate good-practice.
200.130.F.2 Training/Competency Requirements. Training and competencies required
to undertake the duties of an Occurrence Investigator are:
Mandatory
a.

RAF Human Factors Foundation course.

b.

RAF Error Management Foundation course.

c.

Occurrence Investigator course.

d.

Occurrence Review Group course.

e.

ASIMS DLP Training all role groups.

AP3207 Manual of Flight Safety, FS200.120

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AP 3207

200.135 JUST CULTURE POLICY

200.135.1 INTRODUCTION
200.135.2 The RAF is committed to creating and sustaining a positive safety culture.
This will include the adoption of an RAF Aviation Error Management System (AEMS) in
support of the implementation of a planned Defence Aviation EMS (DAEMS). The
adoption and implementation of the Just Culture policy in this document is a key enabler to
the delivery of AEMS. The Open reporting process required to make AEMS successful
depends on a belief among the workforce that if they report their mistakes and near
misses (as they will be encouraged to do) they will be dealt with in a just and consistent
manner.
200.135.3 Just Culture Policy Statement
200.135.4 The RAF is committed to establishing, publishing, promoting and
demonstrating a just culture policy that encourages personnel to report maintenance
accidents, incidents, errors or near misses without fear of inappropriate punitive action. It
recognises that a just culture will benefit the Service by enhancing the moral component of
fighting power and ensuring a more refined management of personnel and risk.
200.135.5 The RAF Just Culture Framework will promote:
a. A set of beliefs and behaviours that underpins a just culture
b.
Consistency in the way occurrences and near misses are investigated and
dealt with.
c.
Adoption by Unit Commanders of the Flowchart Analysis of Investigation
Results (FAIR) as part of a process for analyzing events, including to determine if
there is any culpability, by focusing on actions and intentions, rather than
consequences.
200.135.6 The Just Culture Framework is not intended to replace current disciplinary or
administrative procedures but instead to encourage a transparent and fair analysis of
behaviour and provide guidance on the most appropriate actions to reduce the likelihood
of recurrence of an unwanted event.

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AP 3207

200.135.7 Just Culture Beliefs and Behaviours

200.135.8 The beliefs and behaviours outlined in Table 1 establishes a code of conduct to
underpin the RAF AEMS Just Culture:
Beliefs

Behaviours
Proactive ownership and engagement from the
Senior Leadership throughout the organization.

(1) Recognize professionals will

occasionally make mistakes.

Ability to raise your hand and admit I have

made a mistake.
Ability to raise your hand when you see risk.

(2) Recognize even professionals will

develop unhealthy norms.

Ability to manage risk at the appropriate level.

Fierce intolerance of reckless behaviour.

(3) Be fiercely intolerant of reckless

conduct.

Encouragement of uninhibited reporting without

fear or embarrassment.
Active participation in the AEMS reporting
process to help create a learning culture.

(4) Recognize inappropriate blame gets in

the way of error management.

Qualified immunity from sanctions that is

understood by everyone in the organisation.
Clear understanding of line in the sand.

Table 1 Just Culture Beliefs and Behaviours

200.135.9 IMPLEMENTATION OF A JUST CULTURE IN THE AEMS PROCESS
200.135.10
The process diagram in Annex A illustrates how the FAIR system is to be
used in the consideration of accidents, incidents, errors or near misses.
200.135.11
Where appropriate, the Occurrence Review Group (ORG) will make
recommendations regarding appropriate disciplinary or administrative action; however, it
will remain the responsibility of the command chain (with appropriate legal advice if
necessary) to determine and enact any action in accordance with Service procedures.
200.135.12
The FAIR system in Annex B comprises a flowchart to determine
behavioural classifications based upon information gathered during an investigation, and a
framework for assessing the relative levels of culpability or accountability ascribed to those
behavioural classifications.
200.135.13

A glossary of terms used within the model is included in Annex C.

200.135.14
Application of the model requires a degree of sensitivity and discretion but
will ensure an impartial and consistent judgement as to what are deemed acceptable and
unacceptable actions. It relies upon a complete and comprehensive investigation having
been conducted by trained personnel and should not be used in isolation or without the
support of such an investigation.
200.135.15
Application of FAIR will lead to one of eight behavioural classifications
which can be separated into one of three categories:
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AP 3207

a. Unintended action / unintended consequence: where neither actions nor

consequences were as intended. Actions in this category would be deemed errors.
b. Intended action / unintended consequence: where the actions were as planned
but the consequences were not. This category contains the majority of the
behavioural classifications including mistake, situational rule-breaking, exceptional
rule-breaking, rule-breaking for organizational gain, rule-breaking for personal gain
and recklessness.
c. Intended action / intended consequence: where both actions and
consequences were as planned. Actions in this category would be deemed
sabotage.
200.135.16 Guidance Material - Implementation of a Just Culture in the AEMS
Process. FAIR is intended for use by a suitable ORG that would use the nonjudgemental results of an investigation where a question of culpability arises due to the
actions of an individual or group of individuals. The determining factor that will enable the
ORG to establish if there is any culpability will be the question of intention: were the
actions and ensuing consequences intended by the individual?
200.135.17 PROCEDURE FOR USING THE FAIR SYSTEM
200.135.18
Employing a Just Culture amounts to classifying the behaviour and then
conducting a was it reasonable trial by applying the Routine Test and the Substitution
Test to the situation.
200.135.19
Using the FAIR flowchart, the ORG is to answer the questions posed
based on the information gathered during the investigation. Should clarification or further
information be necessary to answer the questions, the ORG is to verify any issues with the
Occurrence Investigator (OI) team before continuing with the analysis. The individual
circumstances of an event will dictate how the response to each question is determined.
200.135.20
Having responded to the questions, one of a number of behavioural
classifications will be reached. These are:
a. Error. An action that does not go according to plan.
b. Mistake. Action that goes according to plan but where the plan is inadequate
to achieve the desired outcome.
c. Situational rule-breaking. Deliberately not following rules was the only way to
complete task.
d. Exceptional rule-breaking. Deliberately not following rules in unforeseen or
undefined situations.
e. Rule-breaking for organizational gain. Deliberately not following rules with
the aim of benefiting the organization.
f. Rule-breaking for personal gain. Deliberately not following rules with the aim
of benefiting the individual.

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AP 3207

g. Recklessness. Conscious, substantial and unjustifiable disregard of visible

and significant risk.
h. Sabotage. Malicious or wanton damage or destruction.
200.135.21 Behaviour Classification. The following is a guide to issues that are to be
considered when answering the specific FAIR flowchart questions:
a. Was there a CONCIOUS, SUBSTANTIAL and UNJUSTIFIABLE disregard for
risk? Did the individual knowingly take a significant risk whilst ignoring the potential
for harm that could be caused to others?
b. Was there malicious intent? Did the individual set out to cause a bad event?
c.
Were rules intentionally broken? Did the individual knowingly contravene
rules or not follow procedures in order to undertake the task?
d.
Was a correct plan of action selected? Would the plan of action selected
by the individual have ever achieved its goal?
e.
Could the task have been done in accordance with the rules? In the
circumstances in which the individual found themselves, was it possible to complete
the task in line with rules or procedures?
f.
Was the situation outside normal practice? Did the individual find
themselves in a situation which differed considerably from the usual operating
environment?
g.
Was the action to benefit the organization? Did the individual consider that
their actions were for the good of the organization or business or were they based
upon blatant self-interest?
200.135.22 Having responded to the questions in FS200.135.21, one of a number of
behavioural classifications will be reached. These are:
a.
Error. An action that does not go according to plan. Errors can either be
due to an individual doing something other than what they intended to do (an error
of commission) or failing to do something because of an issue with concentration or
memory (error of omission). For example, misinterpreting information on a gauge;
pulling an incorrect circuit breaker; forgetting to complete the last step of a task
because of an interruption.
b.
Mistake. Action that goes according to plan but where the plan is
inadequate to achieve the desired outcome. Known as a cognitive error, a mistake
occurs when an individual does what they planned to do, but where they should
really have done something else if they wanted to achieve their goal. For example,
using out of date information to perform a task.
c.
Situational rule-breaking. Deliberately not following rules was the only
way to complete task. Individuals may assert that, given the circumstances in
which they found themselves, that the only way to get the task done was to break

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the rules. For example, not using the correct equipment to do a task as the
equipment was unserviceable at the time.
d.
Exceptional rule-breaking. Deliberately not following rules in
unforeseen or undefined situations. Not every situation can be anticipated and
when individuals find themselves in extraordinary circumstances, they may find that
they are acting contrary to the rules.
e.
Rule-breaking for organizational gain. Deliberately not following rules
with the aim of benefiting the organization. An individual may believe that their
actions were for the good of the organization in terms of a reduction of time, cost or
resource; also in the avoidance of potential losses or achieving organizational goals
such as meeting schedules or targets. For example, missing out steps in a task that
are judged to be superfluous in order to meet a deadline set by management.
f.
Rule-breaking for personal gain. Deliberately not following rules with
the aim of benefiting the individual. Actions can be corner-cutting to complete a
task more quickly or to circumvent seemingly laborious procedures. They can also
be thrill-seeking as a means of alleviating boredom or as a demonstration of ability
or skill. Motivational in cause, such rule-breaking can be encouraged or condoned
in the drive to meet targets. For example, not completing a task to get away from
work on time; not using the correct equipment because it requires effort to obtain.
g.
Recklessness. Conscious, substantial and unjustifiable disregard of
visible and significant risk. Whilst there is no intent to do harm to others,
recklessness implies that an individual knowingly ignored the potential
consequences of their actions. For example, coming into work under the influence
of alcohol.
h.
Sabotage. Malicious or wanton damage or destruction. To determine
whether an individuals actions constitute sabotage there needs to be intent for both
the actions and the consequence to cause damage, disrupt operations or incite
fear.
200.135.23 ASSESSING CULPABILITY
200.135.24 The FAIR system aligns behavioural classification with a relative level of
culpability determined largely by the intention behind both actions and consequences. A
notional line in the sand is employed to distinguish between behaviour which is
undesirable but to some extent understandable, and that that which is in all senses
unacceptable to the organization. However, culpability can not be assessed from the
behaviour classification alone; the routine and substitution tests must now be employed.
200.135.25 The Routine Test.
200.135.26 Has this event happened before to either the individual or to the
organization? This test seeks to ascertain whether:
a.
The actions of the individual are in fact normative, that is, that they are a
reflection of the normal way of working (this should align with the findings of the
substitution test below); or

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b.

The individual has been involved with similar occurrences previously; or

c.
The organization has experienced similar occurrences previously but that
remedial actions failed to prevent recurrence (eg replenishing a propulsion system
engine oil tank with an incorrect fluid).
200.135.27 Establishing whether the behaviours are routine or whether the event has
happened previously will have a direct influence upon determining the most appropriate
intervention.
200.135.28 The Substitution Test.
200.135.29 Would another ordinary person with the same competence behave in the
same way in the same circumstances? If the answer is yes, then it is inappropriate for the
individual to be deemed culpable. This should be an evaluation by the ORG based on
information gathered from a suitable peer group during the investigation.
200.135.30 This test is used to assess whether another individual sharing the same
knowledge, experience and perceptions; special skills, education and training; physical
characteristics and mental capacity might have reasonably followed the same course of
action given the same circumstances.
200.135.31 DETERMINING APPROPRIATE INTERVENTIONS
200.135.32 The principle aim of a Just Culture and the employment of the FAIR system is
to deliver interventions that will most effectively minimise the likelihood of recurrence of an
unwanted event. For an intervention to be successful it needs to be appropriate to the
type of behavioural classification determined by the FAIR system.
200.135.33 Errors, mistakes and rule-breaking all have differing psychological and
motivational precursors and it is essential therefore that consideration is given to this
when developing an intervention. Intervention strategies will be determined by the
outcome of the routine and substitution tests in consideration with the initial assessment of
culpability. Such interventions may be at one or more levels, from the organisation
through to the individual, and delivered through the management of performance
influencing factors..
200.135.34 In some circumstances the FAIR system may suggest that administrative or
disciplinary measures are appropriate. In these cases, when making its recommendation
to the command chain regarding appropriate action to take, the ORG must consider the
Proportionality Test and determine an intervention suited to the overall level of culpability
when considered in the light of both the routine and substitution tests.
200.135.35 The Proportionality Test. What safety value will punishment have? This test
should be used to determine the appropriate extent of any administrative or disciplinary
action in terms of its contribution to safety learning and improvement.
200.135.36 JUST CULTURE ACCESS TO REVIEW. Ultimately, it is the role of the chain
of command to foster a Just Culture. There are, however, instances where actions arising
from Air Safety occurrences and investigations may appear not to comply with the
provisions of this section. In those instances, an individual may contact the I of FS either
directly or confidentially via a DCOR, at which point a review of the circumstances will be
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undertaken by RAF Flight Safety on behalf of CinC Air to determine whether Just Culture
policy was correctly applied. In circumstances where there has been a clear deviation
from this section, I of FS will prepare and submit a recommendation to DCinC to assure
compliance with Just Culture policy.
Annexes:
A. FAIR System and AEMS Process Diagram.
B. Just Culture Flowchart Analysis of Investigation Results (FAIR).
C. Just Culture Glossary of Terms.

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ANNEX A TO
ORDER 1.8

FAIR System & AEMS

Further
information,
as required

Hazard/
Near-Miss/
Occurrence

Carry out
Investigation
using EDA
and Trained
OI(s)

Immediate
Precautionary
Action
Required?

Occurrence
Review Group
(ORG)
Convened

FAIR System

Take
Disciplinary or
Administrative
Action

ORGs
Recommendations
to LM on Culpability

No Further
Action
Regarding
Person
NonJudgemental

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Judgemental

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FAIR (Flowchart Analysis of Investigation Results) System

ANNEX B TO
ORDER 200.135

START

Was there a conscious,

substantial and
unjustifiable disregard
for risk?

Was there
malicious intent?

Yes

Sabotage or
attempted sabotage

Yes

No
Recklessness
No

Were rules
intentionally broken?

Could the task have

been done in
accordance with the
rules?

Yes

Yes

No

Was a correct plan of

action selected?

Was the action to the

benefit of the
organization?

No

Yes

Error

No

Rule-breaking for
personal gain

No
Mistake
Was the situation
outside normal
practice?

Yes

Exceptional
rule-breaking

No
Situational
rule-breaking

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Yes

Rule-breaking for
organizational gain

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FAIR (Flowchart Analysis of Investigation Results) System

Unintended Action
Unintended Consequence

Intended Action
Unintended Consequence

Error

Mistake

nominal line in the sand

Situational
rule-breaking
Exceptional
rule-breaking
Rule breaking for
organizational gain

Increasing

Intended Action
Intended Consequence

Rule breaking for

personal gain
Sabotage
Recklessness

Culpability

ASSESS

Tests applied to determine level of culpability:

1. Substitution Test: Would another ordinary person with the same competence (education, training and experience) behave
in the same way under the same circumstances (time, goal, demands, organizational context)?

No Culpability

2. Routine Test: Does this happen often to: 1. the individual; or 2. the organization?

MANAGE

Proportionality Test: if culpability is evident, the proportionality test is applied to determine the safety value of administrative or
disciplinary action.

Managed by improving performance influencing factors (person, task, situation and

environment). In some cases, dependent on the outcome of the above tests, administrative
or disciplinary action may be necessary.

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Likelihood that administrative or disciplinary measures will be

appropriate. The improvement of performance influencing factors
should remain a consideration.

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ANNEX C TO
ORDER 200.135

JUST CULTURE GLOSSARY OF TERMS

Error

Action that does not go according to plan

Exceptional rule-breaking

Deliberately not following rules in unforeseen or undefined

situations

Intended action

Action that goes according to plan

Intended consequence

Outcome as planned

Intentional rule-breaking

Deliberately not following rules

Intervention

What needs to happen to reduce likelihood of recurrence at

an individual or organizational level?

Mistake

Action that goes according to plan but where the plan is

inadequate to achieve the desired outcome

Normal practice

Usual operating environment

Optimizing rule-breaking for

organizational gain

Deliberately not following rules with the aim of benefiting the

organization

Optimizing rule-breaking for

personal gain

Deliberately not following rules with the aim of benefiting the

individual

Proportional punishment test

What safety value will punishment have?

Recklessness

Conscious disregard of visible and significant risk

Routine test

Has this event happened before to the individual or

organization?

Rules

Prescribed regulations, policies or procedures

Sabotage

Malicious or wanton damage or destruction

Situational rule-breaking

Deliberately not following rules as only way to complete task

Substitution test

Would another ordinary person with the same competence

(education, training and experience) behave in the same way
in the same circumstances (time, goal, demands and
organizational context)?

Unintended action

Action that does not go according to plan

Unintended consequence

Outcome not as planned

Unintentional rule-breaking

Unknowingly not following rules

ANNEX C TO
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200.140
FLIGHT SAFETY PROCEDURES ON OPERATIONS

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200.140 FLIGHT SAFETY PROCEDURES ON OPERATIONS

200.140.1 INTRODUCTION
200.140.2 To leave Force Commanders the discretion to tailor their actions according to
circumstances, flight safety administration and oversight should fall within their own
command structure. Nevertheless, for operational and engineering reasons, it is vital that
all occurrences during operations are still reported, investigated and administered in
accordance with extant MAA and RAF requirements to ensure that further likelihood of
occurrence and loss is kept as low as reasonably practicable and that no valuable lessons
or data are lost. The relevant Duty Holder should be kept closely informed of theatre Air
Safety issues, as, per MAA Regulatory Notice 1 he will retain responsibility for the
continued management of all routine operating risks in theatre.
200.140 REPORTING REQUIREMENT
200.140.1 Deployed Unit Flight Safety Officers. During Operations, every effort will be
made to retain normal peacetime flight safety awareness and practices in accordance with
Operating Authority guidelines. Suitably-qualified UFSOs are to be identified within formed
units 2 prior to deployment and will ensure the unit complies with reporting procedures set
out in MRP RA 1410. Examples of these formed units would be a deployed force element
(ie: GR4/UK Sentry in support of UK or NATO ops/1 ACCS/formal deployment of RAF
EAW). Additionally, they are to ensure that any reports indicating potential airworthiness or
impact on safe operations are immediately entered in the ASIMS database and that the
ASIMS Occurrence Manager 3 at the home stn and in-theatre are informed of the relevant
occurrence reference number.
200.140.2 Reports affecting other Commands or Air Forces. Occurrence reports that
are likely to affect other Services, commands or air forces will be released to external
agencies through the theatre Force Commands Flight Safety structure in accordance with
MRP RA 1020, and not via the UFSO, unless otherwise directed by the Force Commander or
higher authority.
200.140.3 Flight Safety Investigation During Operations, Hostilities and War. During
operations, hostilities and war, any aircraft losses are to be reported as soon as possible
using the D-ASOR System if possible. It is foreseeable that the aircraft may not be recoverable
or must be denied to hostile forces on direction of higher authority. Every effort is to be made
to retain all relevant documentation and data relating to that aircraft and crew, to enable a more
detailed investigation to take place at a more suitable time and location. However, under
certain conditions it may be possible to conduct an investigation into the circumstances of the
loss, particularly if the accident has occurred in friendly territory. In all cases, UFSOs are to
take notes from

MAA/RN/05/11(DG) Aviation Duty Holder Responsibilities in Operations- to be formally included in MARDS under new section
reference.
2

Not all formed units are of sufficient size and duration to justify or make practicable provision of a UFSO within the section. These
units will have, however, nominated an individual to manage flight safety issues during the detachment. In such instances, the
overarching EAW and/or theatre should act in the stead of a UFSO. This is anticipated to be the exception, rather than the norm,
however.
3

RAF Station Occurrence Managers are ordinarily Station Flight Safety Officers.

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formation members who have witnessed the loss of an aircraft. Details of the
circumstances should be retained, pending any investigative action at a later date.
200.140.4 Losses over Friendly Territory. If an aircraft is lost over friendly territory,
every effort is to be made to recover the ADR (if fitted). When the ADR is recovered it is to
be dispatched on direction of the MAA without delay for analysis. If there is a requirement
to recover or destroy any classified equipment from the crashed aircraft, great care is to be
taken not to destroy other evidence which may be vital to a subsequent investigation. In
the event of an MAA SI, it is anticipated that the Military Aviation Accident Investigation
Branch will deploy with an MAA Service Inquiry Advisor, who are to be afforded full
cooperation to the extent it does not unjustifiably endanger personnel, RAF property
and/or operational capability.
200.140.5 Cessation of Hostilities. After the cessation of hostilities, a specialist team
comprising experts from MAA, RAF and DE&S may be sent to examine accident sites in
areas which were previously behind enemy lines. They should be tasked to recover ADRs.
In the longer term, diplomatic assistance may be needed to retrieve ADRs from aircraft that
have been lost deep in enemy territory.

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200.145
OCCURRENCES INVOLVING NON-RAF AIRCRAFT

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200.145 REPORTING AND INVESTIGATION OF ACCIDENTS AND SERIOUS

INCIDENTS TO NON-RAF AIRCRAFT
200.145.1 INTRODUCTION This Section outlines the actions required following an
accident or serious incident to a non-RAF aircraft at, or in the vicinity of, an RAF unit or
operated by the RAF or RAF personnel. 1 Guidance is also provided on the extent of RAF
responsibility for, and participation in, the subsequent investigation. The Chapter is subdivided according to the category (ie MOD(PE), Service, NATO, non-NATO,
Commonwealth) of the operating country of the aircraft concerned.
200.145.2 DE&S Aircraft and Aerosystems
200.145.3 Reports. Occurrences to DE&S aircraft are to be reported using the
procedures laid down in Section 200.105. The ODH, Comdt Air Warfare Centre and MOD
BOSCOMBE DOWN should be included as an action addressees.
200.145.4 Investigations. In general, accidents and incidents to aircraft belonging, or on
loan, to DE&S which involve solely civilian or foreign personnel will be investigated by the
MAA should it be necessary to convene an SI. Wherever RAF personnel or equipment are
involved in an incident involving DE&S aircraft where an SI has not been convened by the
MAA, Section 200.120 will apply, with the ODH and AWC CTP acting as DDH. An RAF
Unit-Level Investigation will be undertaken by these two Duty Holders pursuant to Section
200.120.
200.145.5 ROYAL NAVY(UK)
200.145.6 Initial Notification. When an accident or serious incident to a RN aircraft in
UK has caused casualties or is likely to attract public attention, the Royal Navy Fleet Air
Arm is to be telephoned with full details as soon as possible on the following 24-hour
extension: +44 7900134946. In addition, the telephone message should be passed to
IFS(RAF) (see Sec 300.105.20 et seq).
200.145.7 Follow-Up Reporting. Follow-up reporting should occur via submission of a
DFSOR by the RN.
200.145.8 Other Reports. If required, the CO of the reporting RAF station may be asked
to submit a written report, which should be copied to the ODH and IFS.
200.145.9 Investigation. Investigation normally will be conducted by the appropriate
Naval authority. If RAF aircraft, personnel or equipment are involved, investigation
instructions will be issued by the ODH in consultation with IFS (RAF) after consultation
with the RN.

200.145.10 Joint Helicopter Command. Accidents and serious incidents to JHC aircraft
should be reported using the procedures in Sec 205.105. Reporting and investigation are
the same as those for the RN, commencing at Sec 200.145.5. Initial notification of JHC
should occur via the following numbers: +44 1264 381485 / 96770 1485 (UK Duty Hours)
and +44 7717 451967 (Out of UK Hours).
1

Non-RAF Aircraft is defined as those aircraft not registered to, operated by or on behalf of the RAF; this includes charter aircraft
transporting RAF personnel, equipment or conducting testing on behalf of the RAF. This does not include an RAF aircraft operated by
another agency (ie: AWC).

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200.145.11 ARMY The procedures set out for Royal Navy (UK) in Section 200.145
should be followed reference the Army, contacting Army Aviation at +44 1264 784180 or
24-hour mobile at +44 7768 988210.
200.145.12 NATO. The procedures to be followed when reporting and investigating
military aircraft/missile accidents and incidents involving 2 or more NATO nations are laid
down in STANAG 3331 (Investigation of Aircraft/Missile Accidents/Incident The STANAG also
applies to accidents and incidents involving both civil and military aircraft of NATO nations.
Unlike RAF procedures, the STANAG does not cover apportionment of blame, neither does
it include assessment of liability; such investigations should be conducted independently
under the laws of the nation concerned. Each nation involved may exercise its sole discretion
to participate in a NATO combined investigation or to conduct its own separate investigation.
For the RAF, past experience has shown that it is preferable for a NATO combined investigation
to assemble and report its findings before any further national inquiry is convened. The
findings of the combined investigation should then be used as the basis for the national
inquiry. Wherever possible, member nations should exchange information which does not
compromise security or conflict with practices regarding privilege. The following
paragraphs provide a guide to the requirements of STANAG 3531 as they apply to the
RAF.
200.145.13. Overall Co-ordination. IFS (RAF Flight Safety) is responsible for initiating
and co-ordinating actions to meet the requirements of STANAG 3531. This includes
liaison with the MAA and relevant Air Attach(s) and the issue of invitations for nations to
send/attend accident investigations. Such action will be taken in close consultation with
host-nation convening authorities so as to meet their investigation requirements as well as
those of the other NATO nation(s) involved.
200.145.14. NATO Occupied Airfields. Nations which suffer accidents to their own
aircraft on their own airfields abroad (eg RAF in Cyprus, USAFE in Europe) are
responsible for taking their own reporting/investigation procedure.
200.145.15. RAF Accidents Abroad in NATO Countries. When an accident or serious
incident occurs to an RAF aircraft in a NATO country abroad, for example RAF operations
in Op Ellamy from Gioia del Colle, Italy, the STANAG requires that country to provide initial
rescue, reporting and wreckage guarding. For fatalities, the local military authorities will
ensure that the requirements of the civilian authorities and the wishes of the Service are
met as far as possible. The form of the accident investigation, as laid down in the
STANAG and outlined at paras 23 and 24 of this chapter, will be notified by the MAA in
consultation with both the RAF and the appropriate military and national staffs of the
foreign country.
200.145.16. NATO Accidents in UK. When an accident or serious incident occurs to a
NATO aircraft in the UK, the nearest RAF station to the scene (see Section 200.150) is to
take the following immediate action:
a.
Provide all possible assistance to aircraft occupants, ensure removal and care
for all casualties and provide guards for the aircraft in accordance with normal RAF
procedures. (Note that civilian authority is ordinarily responsible for casualty
removal).

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b.
Report the occurrence by telephone (United Kingdom and RAF in Germany
only) or by signal message (commands abroad see Sec 200.105) to:
(1)

IFS (RAF Flight Safety).

(2)

Their parent group and command.

(3)

The parent unit of the aircraft, if known.

(4)

Additional addresses as relevant.

c.
Request RAFCAM to initiate any necessary investigation in accordance with
STANAG 3318 (Aeromedical Aspects of Aircraft Accident/Incident Investigation) held by MOD DMSD (Health 4) related document F Med 154.
d.
Despatch immediately a suitably qualified officer to the scene of the occurrence
to collect all possible written statements and other evidence (see para 23c), in
anticipation of an investigation. This officer will subsequently be attached to and
assist the foreign investigating board. 2
e.
Fatalities. When fatal accidents occur, the following additional action is to be
taken:
(1) The officer attached to the foreign investigating board (see sub-para d
above) is to ensure that all necessary legal action required by the local civilian
authorities is taken.
(2)

The station is to observe the honours prescribed under RAF procedure.

(3) Final disposal of bodies is to be made in accordance with the wishes of the
nation(s) concerned.
The subsequent investigation will be either national (see Sec 200.145.16) or combined
(see Sec 200.145.17) as decided by the MAA and IFS (RAF Flight Safety) in consultation
with appropriate convening and national authorities.
200.145.17.
National Safety Investigation Procedure. The following general rules
govern national investigation procedures:
a.
The investigation is the responsibility of the nation operating the aircraft/missile
concerned. In the UK, if the operating nation is unable or does not wish to make an
investigation, the responsibility will lie with the UK as the nation on whose territory the
accident occurred.
b.
An officer (or officers) of the nation where the accident occurred may, with the
concurrence of both countries, be attached to the operating nations investigating
committee as an official assistant or observer. This officer (or officers) will, if
necessary, provide an interpreter. All arrangements for the attendance of observers,

The MAA may wish to provide an investigator to fulfil this requirement. The nearest RAF station should nonetheless despatch such an
individual until an MAA investigator arrives.

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both RAF and NATO foreign, will be made by IFS (RAF Flight Safety) and/or the
MAA.
c.
In the UK, the authorities of the operating nation will send their investigating
board to the scene of the occurrence after notifying IFS (RAF Flight Safety) of their
intention. Any RAF officer despatched to the scene of the occurrence is to be
attached to and give every assistance to the foreign investigating board on their
arrival. When the board have completed their investigations, he is to forward a brief
report through the usual channels to IFS (RAF Flight Safety) summarising the
practical and administrative problems encountered.
d.
A specialist medical officer with aeromedical qualifications (in the UK, as
nominated by CAMS) will initiate any necessary medical investigation in accordance
with STANAG 3318 (Medical Aspects of Aircraft Accident Investigation) and
subsequently, where necessary, will assist the medical member or adviser to the
investigating board. Reports submitted to investigations by RAFCAM should be
copied to the MAA and IFS (RAF Flight Safety) for information.
e.
Subject to security limitations, information required by the foreign investigating
board is to be made available to them.
200.145.18. Combined Investigation. Accidents or incidents which involve aircraft,
equipment, facilities or personnel of one or more NATO air forces, including the RAF, may
be investigated by a combined investigating committee. (Note: combined investigation,
combined investigating committee and similar uses of the word combined in the context
of an investigation into a NATO occurrence under STANAG 3531 must not be confused
with the use in the UK of Combined Accident Regulations for investigating military/civil
accidents as discussed at Chap 10, para 4 et seq). The following general rules govern
combined investigation procedures:
a.
Legal, Disciplinary and Claim Aspects. The purpose of the combined
investigation procedure is to determine the cause of an accident or incident and to
suggest possible means of preventing a recurrence. Some nations, however, permit
the results of investigations to be used in disciplinary or legal proceedings, or for the
determination of responsibility for claims. Before any evidence is heard, nations
involved in a combined investigation convened in accordance with STANAG 3531
must agree whether the proceedings may be used for legal, disciplinary or claims
purposes. If they do not so agree but a nation requires evidence for legal,
disciplinary or claims purposes, that nation may conduct a separate investigation. If
agreement cannot be reached, this fact is to be reported to the MAA via IFS (RAF
Flight Safety) who will decide whether the MAA/RAF will participate in the combined
investigation. If at any time the combined committee considers that facilities or
personnel of the RAF were a factor in the occurrence, the RAF officer attached to the
committee will be so informed. This fact is to be reported to the MAA via IFS (RAF
Flight Safety) who will decide whether the RAF will continue in the combined
investigation or whether a separate investigation will be required. If the character or
professional reputation of an officer, airman or civilian employee in Crown service is
likely to be affected a board or unit inquiry is to be convened on the instructions of the
MAA in consultation with the RAF. Any nation may conduct a separate investigation
with procedures not necessarily in accordance with STANAG 3531.

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b.
Composition of Combined Investigating Committees. Combined investigating
committees will comprise the investigators and technical advisers considered
necessary by each of the nations involved; the composition of the RAF element is to
be determined by the HQ Air in consultation with IFS (RAF Flight Safety). NATO
nations participating in combined investigations in the UK or RAF commands abroad
will inform MOD of the names of the officers comprising their investigating group and
will designate its senior member; normally the senior RAF member is to be president
of the combined investigating committee.
c.
Combined Investigation Co-ordinating Group. The investigating committee is to
work under the direction of a co-ordinating group composed of the senior members
from each nations investigating element. The co-ordinating group is responsible for
the overall direction of the investigation. It will organise the investigating committee
into specialised sub-committees, as necessary, and will conduct the investigation in
accordance with normal RAF procedure.
d.
Final Report. The investigation committee is required to report its combined
findings using the following format:
(1)

Factual circumstances.

(2)

Investigation and analysis.

(3)

Findings and conclusions.

(4)

Recommendations.

Statements and exhibits should be attached to the report as required and the
complete report may be rendered separately or as part of any other report required
by nations. The senior member of each nations investigating group should indicate
his concurrence or non-concurrence. Copies of the combined report are to be
forwarded to the nations participating in the investigation. When one nation involved
cannot directly participate in a combine investigation, that nation shall have the right
to request and receive copies of all the original reports and conclusions of the
combined investigation committee. In the event that a combined investigation is not
held because a nation involved has declined to participate, copies of the report shall
not be made available if privileged status precludes release of such papers.
e.
Civilian Damage Additional Assistance to Foreign Investigators. When
damage is sustained, other than to military personnel or property, the RAF command
headquarters of the host station is to ensure that an officer is detailed to assist the
investigating committee in all administrative matters.
f.
Communication with the Press. Statements are not to be issued to the press by
RAF personnel concerned with combined investigations. Statements will be issued
only by Command Secretatiat, but with the concurrence of the senior member(s) of
the nation(s) involved.
200.145.19. Recovery Costs. When one nation carries out a recovery of another nations
aircraft at the other nations request, the payment of the recovery costs shall be as laid
down in STANAG 3113 (related document RAF GAI-J 4016).

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200.145.20. Combined Safety Investigations into Military and Civil Aircraft

Accidents. International investigations of accidents involving civil and military aircraft will
be conducted in accordance with Annex 13 to the Convention on International Civil
Aviation.
200.145.21 USAF
200.145.22 Preliminary Telephone Reports. Preliminary Telephone Reports (see Sec
200.105.21 should be made to the following:
a.

If parent unit is in UK; the parent unit.

b.
If parent unit unknown or outside UK the nearest USAF installation or HQ
USAFE, Ramstein Air Base, Germany.
c.

The parent group of the reporting unit.

d.

IFS (RAF Flight Safety), who will notify the MAA.

200.145.23 Signal Message Report. A signal message should be sent if required to HQ

USAFE.
200.145.24 Other Reports. If appropriate, the CO of the reporting station should send a
written report to all concerned, including IFS (RAF Flight Safety).
200.145.25 USAF Involvement in RAF Accidents. If personnel, aircraft or equipment of
the USAF are involved in accidents or incidents to RAF aircraft or personnel, normal
reporting procedure (Sec 205.105) is to be followed in addition to the action outlined in Sec
200.145.22.
200.145.26 Investigations. The investigation of accidents and incidents involving USAF
aircraft in the UK normally will be conducted by the appropriate US authority. If RAF
aircraft, personnel or equipment are involved, specific investigation instructions will be
issued by IFS (RAF Flight Safety); the rules for combined investigations will be similar to
those applying to NATO aircraft.
200.145.27 RAF Stations Abroad. Accidents and incidents to USAF aircraft operating
from, in or near RAF stns or commands abroad are to be reported in accordance with Sec
200.105. Investigation is to be in accordance with instructions issued by HQ Air, via IFS
(RAF Flight Safety) after consultation with the appropriate USAF authority.
200.145.28 COMMONWEALTH MILITARY
200.145.29 UK. Accidents or incidents in the UK involving aircraft of Commonwealth
forces are to be treated in the same way as those involving RAF aircraft with the exception
of those involving the Royal Australian Navy which should be reported using RN
procedures.
200.145.30 IFS(RAF) Action. On receipt of information, either by telephone, ASIMS or
by accident/incident signal message, IFS (RAF Flight Safety) will consult the appropriate
Commonwealth authority and subsequently issue instructions regarding follow-up reporting
and investigation.
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200.145.31 Abroad. Accidents and incidents in RAF commands abroad involving aircraft
of Commonwealth air forces are to be reported in accordance with Sec 200.105.
Investigation is to be decided by the headquarters concerned after consultation with the
appropriate Commonwealth authority.
200.145.32 OTHER MILITARY. Accidents to military aircraft from non-NATO or nonCommonwealth nations which occur in the UK should be in accordance with Sec 200.105.
IFS (RAF Flight Safety) will inform other relevant MOD departments and the air attach of
the country concerned. The Secretary of State will normally authorise the operating nation
to conduct an investigation, but if the operating nation chooses not to conduct its own
investigation, the MAA may decide to convene an Inquiry. If an investigation or board of
inquiry is conducted by the operating nation, a representative will be nominated to attend
as an observer.

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FS200.150 RAF AIRCRAFT POST CRASH MANAGEMENT (APCM) POLICY

References:
A.

MAA Manual of Post Crash Management.

B.

Command Action Letter 20101210-FS-RAFAT XX233 XX253-CAL

200.150.1 INTRODUCTION The MOD Aircraft Post Crash Management (APCM) Policy
(Reference A) defines the objectives of APCM and the Concept of Operations of how
APCM should be conducted across the MOD.
200.150.2 APCM ROLES AND RESPONSIBILITIES
200.150.3 Section PCM 200.105.3, and Annex D to Section 200 contain those aspects of
APCM that are the specific responsibility of the RAF and Air Command. The purpose of
the RAF APCM Policy is therefore to supplement the Reference and provide information
and direction on how these responsibilities are to be met. This PCM policy is only
intended to apply to those aircraft with over 20kg dry weight.
200.150.4 All RAF Stations with regional APCM responsibilities are listed in Annex A to
Chapter 2 of Reference A. It is usually a function of a stations Ops Wg to co-ordinate the
APCM activities once tasked and these units are to respond in accordance with Appendix
2 to Annex C of Chapter 3 to ref A therefore they are to hold copies at the latest
amendment state and be able to access these readily. In the event of a serious incident
the Ops Controller should ensure that regular SitReps are passed to HQ Air (A3 Ops-Tel
95221 Ext 3340). This will allow HQ Air to field enquiries from interested parties and
reduce the requirement on the Ops Cell to provide information to various different
agencies.
200.150.5 In addition to those Stations with an area responsibility, all flying stations are to
produce a Crash Plan which is subject to annual audit by Gp or Cmd staffs. The station
Crash Plan is to be exercised in accordance with Reference A Section 300. Stations are
also responsible for ensuring that they retain a sufficient number of trained Post Crash
Management Incident Officers.
200.150.6 Annex D to Section 200 of Ref A states that HQ Air, specifically A3 Ops, is
responsible for provision of:
a.
RAF RLO (Regional Liaison Officers) in support of APCM.
b.

Crash site Health and Safety and Environmental Protection Policy.

c.
Policy on the categorisation of crashed aircraft and arranging of salvage
and recovery is contained in MAP 01 Chap 9.
200.150.7 In the first instance, notification of an accident is likely to come via the civilian
emergency services to the Deputy Chief of Defence Staff Duty Officer in MOD. The MOD
Defence Crisis Management Centre publishes an SOP (SOP 201) to detail the immediate
actions for the Duty Officer in the event of an accident.

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200.150.8 OVERSEAS DETACHMENTS

200.150.9 Reference B states that at least one member of any overseas flying
detachment must have completed the Post Crash Management Incident Officers Course.
This is to be reflected in Gp policy in accord with this AP. Following consultation with Gp
HQs, for the purposes of PCM an overseas flying detachment is defined below:
200.150.10 Where more than 3 ac are involved as part of a detachment (typically fast jets
or helicopters), or fewer than 3 ac but for a duration in excess of 7 days, then a PCMIO
trained person is to be part of the detachment. If fewer than 3 ac, or for a duration less
than 7 days, then the requirement for a PCMIO qualified individual is not mandatory, but is
still recommended.
200.150.11 Where ac deploy on an individual basis (typically large or multi-engine ac),
while not practical to mandate that a PCMIO qualified individual is present, it is still
recommended where possible.

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200.155

RAF FOREIGN OBJECT DEBRIS (FOD) PREVENTION POLICY

References:
A.

MRP RA 1400(2)

B.

MAP

200.155.1

01
INTRODUCTION

200.155.2
Foreign Object Debris (FOD) is defined at Reference A as any material
(including loose articles) that originates from any source, either external to or part of an
aircraft, which can cause damage to that aircraft or its equipment. FOD presents a
significant risk to aviation as damage caused by foreign objects could cause catastrophic
failure at any time. Such failure could result in damage to or loss of aircraft and/or
personal injury or death. It is therefore of paramount importance that measures are taken
to minimise the likelihood of FOD occurrences.
200.155.3

AIMS OF FOD PREVENTION

200.155.4
The aims of FOD Prevention are contained at Reference A, but for
reinforcement are repeated below:
a.
Operational and maintenance practices should minimise the likelihood of FOD
being created that could result in damage to aircraft.
b.
Should FOD enter an aircraft or an AOA, processes are in place to remove that
FOD before it can cause damage.
c.
Should FOD cause damage to an aircraft, the design is such that the Aviation
safety risk the FOD poses is As Low As Reasonably Practicable (ALARP).
200.155.5

SOURCES OF FOD

200.155.6
Below are the most common examples of sources of FOD on airfields, ALL
PERSONNEL ON AN ACTIVE AIRFIELD (REGARDLESS OF WHETHER THEY ARE
AIRSIDE OR NOT) HAVE A RESPONSIBILITY FOR FOD PREVENTION:
a.

Personal FOD such as pens, coins, spectacles, headsets

b.
Support equipment particularly tools, but also other test and maintenance
equipment. Specific policy on Tool control is contained in Reference B
c.

Aircraft inventory particularly airframe components becoming detached.

d.

Vehicle borne FOD or parts detaching from vehicles.

e.

Break-up of airfield surfaces.

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200.155.7
HQ AIR COMMAND FOD PREVENTION ORGANIZATION, ROLES AND
RESPONSIBILITIES
200.155.8
Inspector RAF Flight Safety is responsible to CINC AIR for RAF FOD
Prevention Policy. RAF Flight Safety SO3 Policy is the RAF FOD Prevention Officer and
as such has overall responsibility for the management and implementation of FOD
Prevention Policy in the RAF. He is responsible to the Inspector of RAF Flight Safety for
providing FOD Prevention policy for all RAF Main Operating Bases (MOBs), RAF stns with
airfields or helicopter landing sites, Deployed Operating Bases (DOBs) Forward Operating
Bases (FOBs), and all Permanent Joint Operating Bases (PJOBs) where the RAF has
primacy. TORs for the RAF FOD Prevention Officer are at Annex A.
200.155.9

STATION ROLES AND RESPONSIBILITIES

200.155.10
Commanders of aviation-capable units that handle, operate or maintain
aircraft and associated equipment are to appoint a unit FOD Prevention Officer. Sample
TORs for Station FOD Prevention Officers (SFODPOs) are at Annex B.
200.155.11
Commanders of all aviation capable RAF stations are to ensure that their
Unit has a FOD Prevention and Recovery Plan. The plan should be specific to individual
stns and clearly define the Units specific FOD prevention measures in order that:
a.
Personnel across the Unit have access to a single document containing
details on all local FOD Prevention measures.
b.
Standardisation of format across the Service will ensure greater efficiency
in the assurance process.
200.155.12
Aviation capable Units are to run regular FOD Prevention Working Groups
under the chairmanship of the SFSO or appropriate deputy, and with representatives of
Sections around the Unit. Example TORs for Section reps are contained at Annex C.
Working Groups should be held prior to Flight Safety Meetings, and at the same frequency,
in order to provide input to that forum. FOD WG minutes should be made available on
FOD awareness displays.
200.155.13
A template for a Unit FOD Prevention and Recovery Plan is at Annex D.
Commanders should ensure that the content of this plan is reviewed annually.
200.155.14

RAF FLIGHT SAFETY FOD AUDIT

200.155.15
A check of FOD policies at MOBs will form part of the routine Flt Safety
assurance audit process, carried out to a set schedule. Additionally, the RAF FODPO will
carry out ad hoc visits to all MOBs. The aims of these visits are:
a.

To provide assurance that MOBs are complying with extant policy.

b.
To ensure that there is a common minimum baseline for FOD Prevention across
the RAF.

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c.
To provide guidance and support to stn FOD prevention activities, and
encourage Units to develop innovative solutions to their own unique FOD problems ie
tailoring FOD measures to target areas where they encounter particular difficulties.

200.155.16

REPORTING OF FOD OCCURRENCES

200.155.17
Aircraft Damage (Including Aero Engines). The SFODPO is to ensure
that all occurrences of aircraft FOD damage are reported using the DASOR; even if found
after a significant time interval from the event happening to it being discovered. (eg
boroscope inspections). Guidance on FOD reporting and compilation of a DASOR is at
Annex E.
200.155.18
Found FOD. Significant items of FOD found on or close to AOS, or
posing a direct threat to the safety of aircraft should also be recorded on a DASOR.
Where several items are found collocated, or in a similar timescale, then one DASOR
containing a list of all the items can be deemed appropriate. Found FOD of a lesser
nature, or not posing a direct threat at that time, need only be reported and recorded on a
local form (see para 12) and investigated at unit level. The SFODPO is to investigate all
sources of found FOD that present a threat to air safety using the DASOR as a suitable
means of investigation. The SFODPO is to maintain a record of the locations of all FOD
occurrences pertaining to their AOR for a period of not less than 5 years to allow effective
analysis of occurrences.
200.155.19
SFODPOs are to produce a local form to facilitate the reporting,
investigation, and trending of Found FOD. A list of required fields for the local Found FOD
form is at Annex F.
200.155.20
Monthly FOD Summary Report. All SFODPOs are to submit to their Gp
Headquarters, a monthly FOD Summary Report for their AOR. A template for monthly
FOD Reports is contained at Annex G. The Gp HQs will collate this information and pass it
on to RAF Flight Safety SO3 Pol.
200.155.21
Annual FOD Summary Report. In addition to the Quarterly report,
SFODPOs are to submit an annual report for their AOR. This report should cover the
period 1 Apr 31 Mar.
200.155.22
SFODPOs are to submit completed reports to the RAF FOD Prevention
Officer without delay. The format of the reports can be found at Annex F. Annual reports
should be received by the RAF FOD Prevention Officer no later than 30 Apr. Quarterly
reports are required as follows:
a.

NLT 15 Jul (Report to cover 1 Apr 30 Jun).

b.

NLT 15 Oct (Report to cover 1 Jul 30 Sep).

c.

NLT 15 Jan (Report to cover 1 Oct 31 Dec).

d.

NLT 15 Apr (Report to cover 1 Jan 31 Mar).

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200.155.23

FOD TRAINING

200.155.24
Service personnel, Civil Servants, Locally Employed Civilians and
Partnering Organisations. Upon assignment (temporary or permanent) to an aviationcapable station, all personnel are to receive a brief detailing local FOD Prevention
measures and their responsibilities regarding FOD Prevention; this would ideally form part
of the Stn Arrivals procedure.
200.155.25
Works Contractors. The responsibility for FOD prevention briefings to
works contractors rests with the individual responsible for the works services. The
SFODPO should be consulted to provide guidance on FOD prevention measures for all
major works projects and any project in the vicinity of the AOS.
200.155.26

FOD PREVENTION MEASURES AND GOOD PRACTICE

200.155.27

Details of these practices can be found at Annex H.

Annexes:
A.
B.
C.
D.
E.
F.
G.
H.

Terms of Reference for the RAF FOD Prevention Officer.

Sample Terms of Reference for RAF Station FOD Prevention Officers.
Station FOD Prevention and Recovery Plan template.
Sample Terms of Reference for Section FOD Working Group Reps
Guidance on FOD occurrence reporting using the DFSOR.
Local FOD Found Forms.
FOD Summary Report.
FOD Prevention Good Practice.

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Annex A to
RAF FOD Prevention Policy
Dated May 11
TERMS OF REFERENCE FOR THE RAF FOD PREVENTION OFFICER
Reference:
A.

MAA RA 1400

The RAF FOD PO is responsible to Inspector RAF Flight Safety for the following:
1.
Co-ordinating the activities within the RAF areas of responsibility relating to the
prevention of FOD, including:
a.
Ensuring reporting and investigation is carried out in accordance with Sections
200 and 205 of the Reference.
b.
Ensuring FOD Awareness forms part of initial, continuation and specialist
training in accordance with Section 300 of the Reference.
2.
Acting as the focal point in the RAF areas of responsibility for all FOD prevention
activities to ensure that the requirements of MOD FOD Policy are met.
3.

Setting RAF FOD Prevention Policy as part of AP3207.

4.
Ensuring that information and best practice in FOD prevention matters are widely and
effectively publicised to their Station FOD POs.
5.

Reviewing and analysing Station FOD Reports and implementing action as required.

6.

Carrying out Station FOD Audits.

7.
Providing advice to Station FOD POs, PTs, manufacturers and those with the
responsibility for airfield works regarding FOD prevention activity as required.
8.

Representing RAF on the MOD FOD WG.

9.

Providing advice to OOA Cdrs concerning FOD issues.

10. Organising an RAF FOD Prevention Symposium when directed to do so.

11. Maintaining a list of all Station FOD POs at RAF Stations and RAF-led PJOBs.
12. The RAF FODPO is responsible for all RAF Stations, including detachments and
OOA bases.
13. Keeping abreast of wider FOD Prevention issues, initiatives and activities.

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Annex B to
RAF FOD Prevention Policy
Dated May 11
SAMPLE TERMS OF REFERENCE FOR RAF STATION FOD PREVENTION OFFICERS
The Station FOD PO is responsible for:
1.
Monitoring and controlling Station FOD prevention procedures as outlined in MoD
and RAF FOD policies.
2.
Advising and assisting the Station in understanding and executing the FOD
prevention programme.
3.
Ensuring that all FOD incidents and Foreign Object finds are investigated and
reported in accordance with MOD FOD policy and that all FOD occurrence reports are
properly reported to the RAF FOD PO and, in the case of aero-engine FOD damage, to
the relevant engine PT Engineering Authority.
4.

Acting as the focal point to co-ordinate the Stations annual FOD Plod.

5.
Maintaining a record of all FOD incidents on the Station for reference and local
analysis.
6.
Instigating a system to ensure that all aircraft operating areas and associated
technical sites are routinely surveyed to identify possible problem areas and to initiate
corrective action.
7.
Managing and acting as chairman of the Station FOD WG in the absence of the
SFSO, ensuring that regular meetings are held prior holding regular meetings prior to the
Station Flight Safety Meeting.
8.

Providing a FOD briefing to Station Flight Safety Meetings.

9.

Advising Station executives of FOD matters requiring attention.

10. Maintaining liaison with OC Works Services Flt (or equivalent) for minimising the
FOD hazard associated with works services and to ensure the briefing of external
contractors concerning the dangers of FOD prior to their employment on operational areas
of the airfield.
11. Providing quarterly FOD summary reports to the RAF FOD PO at the following
intervals: 15 Jul (Apr-Jun), 15 Oct (Jul-Sep), 15 Jan (Oct-Dec) and 15 Apr (Jan-Mar).
12. Ensuring that FOD prevention is publicised effectively on the Station.
13. Maintaining the Station FOD Website, where applicable.
14. Monitoring and auditing the Station Sweeping Plan and update the plan to take into
account of any major works programmes.
15. Nominating a suitable Deputy Station FODPO.
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16. Instigating a FOD Evaluation (FODEVAL) programme, using the Section FOD WG
members to implement the audit process where possible. A checklist for use in
FODEVALS is at Annex H.
17. Analysing debris from the runway sweeper on a monthly basis.

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Annex C to
RAF FOD Prevention Policy
Dated May 11
TERMS OF REFERENCE FOR SECTION FOD WORKING GROUP REPS
The Sect FOD WG Rep is responsible for:
1.
Monitoring and controlling Sect FOD prevention procedures as outlined in the MOD
and RAF FOD policies.
2.
Attend all Station FOD WG meetings scheduled by the SFSO or FODPO and act as a
liaison between the FOD Working Group, and your Flt/Sect Mgmt/colleagues.
3.
Ensure continuous education of personnel in your AOR and promote FOD
awareness. Advising and assisting the Sect in understanding and executing the FOD
prevention programme.
4.
Ensuring that all FOD incidents and foreign object finds are investigated and reported
in accordance with the Flt/Sect FOD Prevention Plan and that all FOD occurrence and
aero-engine reports are properly reported to the FODPO.
5.
Report, in a timely and accurate manner, all FOD occurrences using DFSOR or Local
FOD Found Form
6.
Establish and maintain a FOD notice board to display FOD awareness material and
current performance indicators.
7.
Initiate FOD sweeps and inspections of your AOR on a regular basis, and maintain
an auditable record of those activities.
8.

Conduct FODEVALS outside your AOR, as detailed by the SFSO or FODPO.

9.
Instigating a system to ensure that all AOS and associated technical sites are
routinely surveyed to identify possible problem areas and to initiate corrective action.
10. Act as a point of contact between your Sect and the ASMT Sect for sweeper request.
11. Ensure contractors in your Sect follow correct FOD prevention practices, and report
bad practice to OC SSS.
12. Nominating a deputy Sect FOD WG Rep.

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Annex D to
RAF FOD Prevention Policy
Dated May 11
STATION FOD PREVENTION AND RECOVERY PLAN (TEMPLATE)
FOD PREVENTION AND RECOVERY PLAN FOR RAF [INSERT STATION NAME
HERE]
1.
Station FOD Prevention Organisation. This section should contain the name and
contact details of the SFODPO, their deputy/deputies and any other personnel with
responsibility for FOD prevention (e.g. FOD Prevention Committee reps, flt/sqn FODPOs).
2.
Station FOD Prevention Measures. This part of the plan should contain 3 separate
sections:
a.
Station FODEVAL Programme. If the Stn has a FODEVAL programme then
details of it should be included in this section. A Template FODEVAL Report is at the
Appendix.
b.
Station FOD-Sensitive Areas. This section should contain a list of all the
areas on the stn subjected to FOD Prevention measures and a list of entry points (ie
FOD checkpoints) to FOD-sensitive areas.
c.
Station Sweeping Plan and FOD Clearance Equipment. This section of the
plan should contain the stn airfield sweeping plan and details of the equipment
available for use to clear FOD along with contact details for ASMT (or equivalent).
3.
Station FOD Recovery Plan. This section should comprise an Op Order for a stnwide visual FOD inspection. The Order should be sufficiently robust that it also remains
applicable to small-scale visual inspections.
4.
Station FOD Reporting Procedures. This section should provide guidance on the 2
methods of reporting FOD occurrences iaw Annex D and Annex F of this Order.
5.
Station FOD Awareness Strategy. This section should contain the following details
and should be read in conjunction with Annex H of this Order:
a.
A statement detailing how and when stn personnel should receive a FOD
Prevention briefing/training.
b.
Details of measures to be taken to ensure that temporary visitors (including
contractors) are made aware of their role in FOD Prevention.

Appendix:
1.

FODEVAL Report Template

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Annex E to
RAF FOD Prevention Policy
Dated May 11

GUIDANCE ON FOD OCCURRENCE REPORTING USING THE D-ASOR

INTRODUCTION
1.
The MOD F7014A was removed from use following the introduction of ASIMS
reporting using the D-FSOR format. Personnel are to use the DASOR to report all
occurrences of aero engine FOD damage and all other major FOD occurrences (including
major finds on AOS). This is a mandatory requirement.
USING THE D-FSOR
2.
There is no separate Form that exists for FOD damage (in contrast to Birdstrike or
Airprox for example which have additional specialist Forms); a single report DASOR will
cover all aspects of the occurrence and FOD investigation as long as it is filled in correctly.
The DASOR should be completed using the ASIMS User Guide on the MAA intranet site
or by using the Link on ASIMS itself. The guidance below is intended to assist with
compilation of DASORs recording a FOD occurrence:
a.
Box A. Occurrence type should be either Air or Maintenance, depending upon
when the damage was caused/found. If tangible damage has occurred, then the
Report is an Incident. If the Report pertains to a significant FOD find which poses a
direct threat to aviation at that airfield (ie a loose article, or an item found on an AOS)
then the Report is a Hazard/Observation. The Local Report Serial Number is a local
reference number and should be set in agreement with the SFSO.
b.
Boxes L to R. The Maintenance Section of the D-FSOR should be completed
by the relevant maintenance organisation: either first-line maintenance personnel if
the damage can be repaired at first-line or by the depth maintenance organization if
depth maintenance is required. Additionally:
(1) Box M. The MOD Form 707 ORN pertaining to the FOD damage should
be entered in box M (this was previously entered on the front page of the MOD
F7014A).
(2) Box O. If engine damage has been sustained, then select Engine from
the Major System Involved drop-down box and FOD Damage in the
Type of Failure/Fault drop-down box.
c.
Box S. The individual responsible for managing the progress of the Report
should enter their details in this box.
d.
Box T. Ensure that FOD Involved is selected, and that the Occurrence
Cause Group is not left blank, but annotated with the most appropriate entry from the
dropdown list. The SFSO can provide additional guidance on the completion of this
section if required
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.
Annex F to
RAF FOD Prevention Policy
Dated May 11
LOCAL FOD FOUND FORMS

The following fields should be included in local Found FOD forms:

1.
A local reference number (for completion by SFODPO to enable occurrence
tracking).
2.

A statement of applicability (e.g. This form is only to be used for).

3.
Details of immediate actions and/or specific actions to be taken upon discovery of
FOD (e.g. actions to be taken upon finding ammunition/tools/aircraft components).
4.

Name and contact details of Reporter.

5.

Date and time of find.

6.
A description of the found FOD and, if required, details of where the Found FOD
should be sent.
7.

A description of the actions taken following the find.

8.

A description of the follow-up actions required.

9.

Details of where the completed form should be sent.

10. A map of the airfield should be included as part of the form to enable the reporter to
annotate the location where the FOD was found.

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Annex G to
RAF FOD Prevention Policy
Dated May 11
FOD SUMMARY REPORT
FOD SUMMARY REPORT FOR RAF [INSERT STATION NAME HERE]
1.

Reporting period:

2.

Number of FOD-related D-FSORs raised during the reporting period:

3.

Number of FOD Finds on Aircraft Operating Surfaces (AOS):

4.

FOD Occurrence Statistics

Aircraft
No. of FOD-attributable
occurrences of airframe
damage
Engine rejection rate per
1000 fg hrs
Engine rejection rate per
1000 sorties

5.

Aircraft Type A

Aircraft Type B

Station total

Significant FOD Occurrences/Trends:

a.
b.

6.

FOD Prevention Measures/Initiatives Introduced:

a.
b.

7.

FOD Prevention Publicity/Awareness/Incentive Schemes Introduced:

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Annex H to
RAF FOD Prevention Policy
Dated May 11
FOD PREVENTION MEASURES AND GOOD PRACTICE
1.
STATION FOD PREVENTION WORKING GROUP. Stn SFSOs should seek
agreement from the Stn Cdr to form a Stn FOD Prevention Working Group (WG). The role
of the WG is to improve Stn FOD Prevention by engaging with personnel from all work
areas on the stn. The WG should contain personnel from across the stn in the guise of
reps from different sections, (to include reps not only from airside sections).
2.
FOD PLODS. Units are to carry out a unit-wide FOD Plod at least once each year.
Additionally, FOD checks of in use aircraft operating areas are to be carried out at least
daily prior to flying operations.
3.
COMPARTMENTALISATION. One of the most effective methods of improving
defences against FOD is to divide the station or airfield into separate areas and give
individual sqns/flts/sections responsibility for FOD Prevention within their AOR. SFODPOs
are strongly encouraged to utilise this methodology.
4.
STN FOD RISK MAP. The creation of a colour-coded stn map can be of great
benefit in reducing the spread of FOD and advising personnel where tyre checks are
necessary. This system can be particularly effective in advising visiting contractors of the
areas that they should avoid. The RAF Marham FOD Zones diagram, shown at the
Appendix, is a good example of a Stn FOD Risk Map.
5.
AIRFIELD OPERATING SURFACES (AOS). Potential sources of FOD should be
minimised through pro-active management of the AOS. There are 4 areas of focus to
reduce the generation of FOD:
a.
AOS Fault Management. Any potential FOD issues arising from unrectified faults or programmed works should be discussed with the unit FOD PO who
should investigate ways to minimize any identified risks.
b.
AOS FOD Migration. Every effort should be made to prevent the migration
of FOD onto AOS. The number of entry and exit points to the operational airfield
should be kept to a minimum and, where practical, entrances to active areas should
be marked with clear, visible FOD warning signs and FOD grids. Tyre checkpoints
placed at all entry points can be valuable in ensuring that all personnel stop and
check their tyres for FOD before driving on the AOS. The use of FOD resistant tyres
should be encouraged. Skips and bins around the unit should have covers and
should not be allowed to overflow. Where a significant risk of migration from
domestic areas exists, units should consider the use of FOD prevention fences.

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c.
Operational Factors. Should FOD be present on an AOS, good
operational practices reduce the likelihood of FOD causing aircraft damage. Where
possible, formation taxiing should be carried out in anti-FOD order to prevent one
aircraft blowing debris into another, and the use of thrust reverse and nozzle braking
should be minimized. Similarly, when undertaking flight line or helicopter operations,
consideration should be given to the risk of blown debris by de-conflicting taxiing
aircraft with ground running areas and helicopter flying.
d.
AOS Clearing. All units are to have an AOS sweeping plan. Ideally all
active AOS should be swept at least once a day with a vacuum runway sweeper.
Other areas including domestic sites should be swept at least once each week to
prevent build up of FOD and migration to operating areas. Debris from airfield
runway sweepers should be analyzed by the unit FOD PO. Confined areas that
cannot be reached by runway sweepers should be swept by secondary sweepers,
such as Precinct Sweepers, FOD BOSS or similar. When operations take place
from grass or unprepared surfaces every effort must be made to remove FOD prior to
all movements.

5.
FOD PREVENTION AND AWARENESS DISPLAYS. SFODPOs are to publicise
FOD prevention as widely as possible. Examples of methods of achieving this are listed
here:
a.
Rolling screen of FOD messages at Guardrooms for visitors as they queue for
passes. In fact use any Station electronic board to carry a FOD prevention message
b.
General use of fixed poster displays at strategic points around station, paying
particular attention to domestic sites as well as AOS.
c.

Information about the Unit FOD Team with names, pictures and contact details.

d.

Minutes of FOD Working Group Meetings

e.
A display board with pictures or live examples of FOD damaged components;
with a full a full explanation.
f.
A Station FOD website and/or an entry on the Stations existing website drawing
peoples attention to FOD prevention.
6.
FOD BRIEFINGS AT STATION ARRIVALS BRIEFS.
A section on FOD
prevention and the particular challenges faced by that Unit should be included in all Station
arrivals Briefs, either as part of the wider Flight Safety Briefing, or as a stand-alone.
7.
IMPART FOD PREVENTION MESSAGE TO ALL PERSONNEL ON UNIT.In addition
to RAF and other military, all Station personnel, to include cleaners, administrative staff,
and civilian contractors should have regular exposure to FOD prevention briefings.

8.
FOD PREVENTION COMPETITIONS AND AWARDS. Encourages a wider
circulation of personnel to give thought to FOD Prevention and the role they play.
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Personnel are rewarded for innovative contributions to FOD Prevention, by way of staging
competitions for the best ideas.
9.
CLAUSES IN WORK SERVICE CONTRACTS. Ensure that a commitment to FOD
prevention is written into potential contract bids at an early stage, and therefore forms an
integral part of any works programme. Contractors could be held to account for their
standards.
10. AIRCRAFT OPERATING PRACTICES. Adherence to good practice in areas such
as parking, taxiing, and formation take-offs can drastically reduce incidences of FOD
damage. Ideally, local orders should be in place to ensure this happens.
11. GPS TRACKING OF FOD SWEEPERS. Supplementary to the Stn FOD Sweeping
Plan, consideration should be given to installing GPS trackers to the FOD Sweeping
equipment. This provides additional assurance that all areas that require sweeping have
been covered.

Appendix:
1.

RAF Marham FOD Zones Diagram.

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Appendix to
Annex G to
RAF FOD Prevention Policy
Dated May 11
RAF MARHAM FOD ZONES DIAGRAM

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FS200.165
FATIGUE RISK MANAGEMENT POLICY

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200.165.1

FATIGUE RISK MANAGEMENT SYSTEM (FRMS)

200.165.2

What is a FRMS?

200.165.3 The RAF FRMS is designed to ensure that RAF personnel at all levels understand the
principles of risks associated with fatigue. The RAFs FRMS provides high level guidance to senior
leadership on the principles of fatigue risk management and the importance of it being integral to
the RAF SMS.
200.165.4

The ICAO FRMS definition is:

a. A means of continuously monitoring and managing fatigue-related safety risks, based

upon scientific principles and knowledge as well as operational experience that aims to
ensure relevant personnel are performing at adequate levels of alertness.
200.165.5
The RAFs aim is to manage fatigue irrespective of the cause, based on science and
empirical findings using data and experience with the objective being to impede fatigue related
errors and occurrences within the Air Safety environment. The RAFs FRMS applies to all
personnel 1 . This policy will require that all personnel adhere to the European Working Time
Directive. Personnel on operational duty are to comply with this policy, where reasonably
practicable. Where there is a need to operate outside this policy, supervisors are to ensure that
the increased risk of fatigue is owned by the appropriate DH.
200.165.6
The RAF FRMS is the top level policy on fatigue. However, in order to meet the
needs of all our fleets and personnel, DHs are to ensure the DH Aircraft Document Set
(ADS)/orders reflect the directives and guidelines stipulated in this document and the ASMP
Section 1, chapter 1.6. The RAF FRMS will represent all RAF Service personnel across 4-worlds 2 .
200.165.7
Implementation of the FRMS. The implementation of the RAF FRMS will be
staged in order to ensure personnel, Safety Training and Regulation (STAR) teams and DHs
receive the appropriate training. Training requirements are covered at 200.65.35. DHs are to
ensure they have reflected the directives and guidelines stipulated within this policy in their own
ADS/orders by 1 Apr 13. During this implementation phase, RAF Flight Safety will be on hand to
assist in the creation of DH specific fatigue policies. The aspiration is for DH AORs to be compliant
by 1 Apr 13.
200.165.8
Fundamentals of a FRMS. The FRMS builds on existing processes and orders
with specific emphasis on fatigue-related hazards 3 . The FRMS integrates with the RAF ASMP by
paralleling existing risk management processes, and demonstrates a commitment to Flight Safety
through a collaborative approach that includes all DH. The advantage of an FRMS over
prescriptive regulations is that DHs can tailor their approach specifically to reduce the fatigue risk.
The RAF FRMS is flexible and adaptable compared to prescriptive regulations which assume one
size fits all and are therefore not easily modified. An FRMS should use scientific principles and
knowledge to reduce the risk of fatigue-related hazards. DHs are to ensure the reporting of fatigue
hazards by all personnel.
200.165.9

FRMS ACCOUNTABILITIES AND RESPONSIBILITIES

MAA02 Master Glossary Describes a collective endeavour to operate in the Air environment safely and embraces any activity that
contributes to the safe operation of military airworthy systems in flight or on the ground.
2

4-worlds Aircrew, ABM, Eng & DSS

Aircrew Fatigue Management - 1Gp GASO Order 345, 2Gp GASO Order 345 and 22 Gp Order 345.100.

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200.165.10 IFS shall be responsible to CAS for the RAF FRMS Policy.
200.165.11 DHs are primarily accountable for the management of fatigue risk, where all other
personnel are responsible to an accountable DH. The FRMS is an organisational system that
enables management to meet that accountability; however, a FRMS can only be effective if all
stakeholders are aware of their accountability/responsibility and have the skills and resources to
meet those commitments.
200.165.12 One of the key features of a risk based approached to a Safety Management System
(SMS) is that all DHs have an accountability for minimising risk and increasing safety. This
approach also applies to the management of fatigue. DHs have an accountability to create a
working environment that minimises fatigue related risk as far as is reasonable practicable, and
personnel have an obligation to ensure that time away from work is used appropriately such that
they are adequately rested before reporting for duty. Within the context of the FRMS, DHs have a
direct accountability and personnel have a responsibility for the management of fatigue 4 .
200.165.13 Responsibilities of Personnel/Employees:
200.165.14 Personnel and Employees shall:
a.
Make appropriate use of their rest periods (between shifts or periods of duty) to obtain
good quality sleep.
b.

Report fatigue-related hazards and incidents through ASIMS 5 .

c.

Inform their chain of command prior to, or during work if:

(1)
They are aware or suspect that they, or another employee, are suffering from
unacceptable levels of fatigue; or
(2) They have any doubt about their, or another employees, capability to
accomplish their duties.

d.
Participate in fatigue risk management training and be aware of local fatigue
management policies.
200.165.15

FATIGUE AWARENESS

200.165.16

What is Fatigue?

200.165.17 ICAO defines Fatigue as; A physiological state of reduced mental or physical
performance capability, resulting from sleep loss or extended wakefulness, circadian phase or
workload (mental and/or physical activity) that can impair alertness and ability to perform safety
related duties.
200.165.18 In simplistic terms fatigue is an experience of physical or mental weariness that
results in reduced alertness. For most people, the major cause of fatigue is not having obtained
adequate rest and recovery from previous activities. In simplistic terms, fatigue largely results from
inadequate quantity or actual quality of sleep. This is because both the quantities and quality of
sleep are of equal importance to recover from fatigue and maintaining normal alertness and
performance. Furthermore, the effects of fatigue can be exacerbated by exposure to harsh
environments (Operations) and prolonged mental or physical work.

DH facing organisations eg. BM have a responsibility towards each DH in ensuring all aspects of this FRMS is adhered to

ASIMS Air Safety Information Management System

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200.165.19
Inadequate sleep (quality and quantity) over a series of nights causes a sleep
debt which results in increased fatigue that can sometimes be worse than a single night of
inadequate sleep. Sleep debt can only be recovered with adequate recovery and sleep. When
personnel work outside the normal routine Monday to Friday hours eg: 0800 to 1700, this can limit
the opportunity for sleep and recovery in each twenty four hour period. This is partly due to the
disruption of the bodys clock/circadian rhythms.
200.165.20 Cumulative and Transient Fatigue. Flight time, duty periods, duty period
limitations and rest requirements are established to enable our personnel to perform at an
adequate level of alertness for safe flight and ground/support operations. Fatigue can be divided
into two types, transient and cumulative fatigue. Transient fatigue is described as fatigue that is
dispelled by a single sufficient period of rest or sleep. Whereas, cumulative fatigue occurs after
incomplete recovery from transient fatigue over a period of time. Personnel on Operational duty
are more at risk of cumulative fatigue due to the working environments and work rate.
Management should consider the cumulative fatigue effect against the requirements of Operational
commitments, especially where personnel are often expected to work for consecutive periods
without adequate rest periods. Management should ensure that where there is an extension of
working time that deviates from DH orders, this is to be elevated to the appropriate DH.
200.165.21
Symptoms of Fatigue. Fatigue-related symptoms can be divided into three
categories: physical, mental and emotional. Table 1 depicts examples of each of these types of
fatigue. If a person is experiencing three or more of the symptoms outlined below, there is an
increased chance that they are experiencing some level of fatigue or reduced alertness. It should
be remembered that fatigue may not be the only cause of the symptoms presented below but if
they occur together, it is a good indication that an individual is fatigued.
Personnel who present three or more symptoms in a short period of time
are likely to be experiencing fatigue-related impairment.
Physical Symptoms
Yawning
Heavy eyelids
Rubbing Eyes
Head drooping
Microsleeps
Irrational decision
making
Irrational reactions
Illogical reactions

Mental Symptoms

Emotional Symptoms

Difficulty concentrating on
tasks
Lapses in attention
Difficulty remembering what
they are doing
Failure to communicate
important info
Failure to anticipate events
or actions
Accidently doing the wrong
thing

More quiet or withdrawn

than usual
Lacking energy
Lacking in motivation to
do a task well
Irritable or grumpy with
peers, family or friends

Table 1.
200.165.22
Causes and Consequences of Fatigue. Fatigue affects all personnel in the
form of physical, mental and emotional tiredness. The result of this tiredness is reduced alertness
which may have a negative impact on performance. The fatigue associated with tiredness and
reduced alertness is different from physical fatigue or weariness which is caused by long hard
physical work. In this case, fatigue may be more accurately defined as mental fatigue although it
certainly affects physical performance as well, especially tasks that require mental-physical
interactions like hand-eye coordination, reaction time and fine motor skills. Other skills that are
impaired by fatigue include attention, vigilance, concentration, ability to communicate information
clearly and accurately, and decision-making. Impairment can lead to fatigue-related errors, which
in turn can lead to incidents or accidents.

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200.165.23
Sleep Science. Sleep is defined as a state of partial or full unconsciousness
during which voluntary functions are suspended and the body rests and restores itself 6 . It is
believed that during sleep, the body recovers from the stresses imposed on it that day and
subsequently prepare for the next days stresses. Prolonged sleep deprivation leads to reduced
mental and physical performance and symptoms such as hand tremors, slurred speech and
increased sensitivity to pain. Both the quality and quantity of sleep are equally important and are
determined by the timing of sleep within a twenty four hour day. Sleep cycles vary throughout the
night and are not uniform; Figure 1 displays these stages. It is important to ensure you receive
sufficient of these stages as they follow each other and can last between 90 and 120 minutes.

Fig 1.
a.
Stage 1 is where we fall asleep. During this initial stage you may occasionally
experience muscle twitches.
b.

Stage 2 is a light sleep where we can be easily be woken.

c.
Stage 3 & 4 are deep sleep cycles. These are the stages where it is considered the
body regenerates and it is usually a difficult stage to be woken up from. Sleep scientists now
refer to stages 3 & 4 together as Slow Wave Sleep (SWS).
d.
Stage 5 or Rapid Eye Movement REM sleep, for. This is the stage where we dream
and is important for learning and memory consolidation.
200.165.24 Depending on the level of fatigue, a sleep deprived person will generally fall asleep
more quickly and move rapidly from light sleep (stages 1/2) to deep sleep (stages 3/4). Unwanted
sleep and fatigue can be considered a hindrance and under certain circumstances it can be
dangerous if for example, in the process of driving a car or piloting an aircraft. Whilst there are
many colloquial strategies to reduce the effects of sleep deprivation and fatigue, they are only a
temporary fix no matter how effective they appear to be. At some point you must sleep to ensure
proper physical and mental recovery. The amount of sleep required will vary between individuals
but it is generally between around 7 and 9 hours. Naturally the body is programmed by their
circadian clock to sleep between approximately 2200 and 0800.
200.165.25 Sleep Inertia. Sleep Inertia is a physiological state characterised by a decline in
motor dexterity and a subjective feeling of grogginess immediately following an abrupt awakening.
There is always a certain amount of sleep inertia, even waking from a short nap, yet the amount
will be fairly limited compared to be woken during slow wave or deep sleep. While both long
sleeps and napping are highly beneficial in combating fatigue, it is important to be aware that
performance and alertness may be impaired for a short period when an individual is woken
suddenly. In essence the longer the nap may increase the period of sleep inertia. Therefore, you
6

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should minimise critical tasks that would be sensitive to sleep inertia for at least 20 minutes after
been woken. Areas such as Quick Reaction Alert (QRA) and Search and Rescue (SAR) are
considered High Risk areas, in which personnel may be on standby for 24 hrs with a strong
likelihood of being woken suddenly and a requirement to react immediately. This particular risk
should either be addressed or managed within the appropriate Group risk register.
200.165.26
Napping. One of the many combatants of fatigue is napping. Short sleeps can
deliver some of the benefits of longer sleeps but over a shorter period. Benefits can be seen in
areas such as improved short-term memory, increased performance, alertness and improved
reaction times. It should be remembered that the benefits of naps are short lived compared to a
full nights sleep. Naps are considered as 20 to 35 minutes in duration. However, the greater the
nap, the longer the benefits will be in terms of recovery and improvements in performance. Yet the
effects of sleep inertia will be greater the longer the nap. An individuals ability to take a nap will
depend on work shifts and fatigue level, but taking a nap in the evening can have a negative effect
on the ability to sleep later in the evening. The advantage of the nap being short is to enable the
body to awake fully prior to entering a deeper sleep stage, which would otherwise cause an
increase vulnerability to sleep inertia.
200.165.27 Jet Lag. When an individual travels across a number of time zones the circadian
clock eventually reacts to the change in light levels plus other factors to adjust the bodys daily
cycle to the new time zone. Before this adaptation is complete, individuals are said to suffer from
jet lag. The adaptation process is affected by a number of factors:
a.

Number of time zones crossed.

b.
The direction of travel adaptation is usually faster following westward travel than
eastward travel across the same number of time zones. This is because most people have a
circadian body clock that has an innate cycle slightly longer than 24-hours, therefore it is
easier to adapt to a westward shift.
c.
After eastward flights across 6 or more time zones, the circadian body clock may
adapt by shifting in the opposite direction, i.e. shifting 18 time zones west rather than 6 time
zones east. When this occurs, some rhythms shift eastward and others westward and
overall adaptation maybe slowed.
d.
Adaptation is usually faster when the circadian body clock is more exposed to the
time cues that it needs in the new time zone. Therefore, the earlier you can adopt the eating
and sleeping cycle in the new time zone, the less effect jet lag will have upon you.
e.
Increased fatigue levels are likely if a person does not adopt to the new time zone and
continues to eat and sleep under their previous time zone. This may result in degraded
performance on mental and physical tasks and mood changes, and minor digestive system
upset.
200.165.28
Circadian Cycles. Circadian rhythms are cyclic processes within the body such
as sleepiness and wakefulness, secretion of digestive enzymes, hormone production and body
temperature. All operating on a cycle of approximately twenty four hours. The cycles are
controlled by the circadian body clock in the brain and determine when the body expects rest and
activity. A key feature of our circadian clock is that it is very light sensitive and the light intensity is
monitored through a network of cells in the retina of the eye. The sensitivity of the circadian body
clock to light enables it to stay in step with the day/night cycle; therefore, those personnel that work
nightshifts, or crews that are required to sleep outside of the normal day/night cycle may disrupt
this process, and these personnel may be vulnerable to fatigue. The daily minimum core body
temperature corresponds to the time in the circadian cycle when individuals generally feel most
sleepy and least able to perform mental and physical tasks. This is sometimes referred as the
Window of Circadian Low (WOCL). For most people the WOCL occurs in the early hours of the
morning around 0300 to 0500 and the afternoon WOCL is said to occur around 1500 to 1700.
During known periods of WOCL, there is a higher risk of fatigue related errors.
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200.165.29
Air/Ground Crew Accommodation. A fundamental aspect of combating fatigue
is to ensure that personnel receive sufficient good quality sleep. Whilst deployed on Operations or
Detachments, there are certain standards that should be met to ensure we give our personnel the
best possible conditions to obtain sufficient good quality sleep. The basic requirement for
accommodation for aircrew as decreed by ICAO is A well furnished bedroom which is subject to
minimum noise, is well ventilated, and has the facility to control the levels of light and
temperature 7 . This requirement is also included within the top level policy regarding RAF
accommodation requirements and entitlement is IAW Air Command Accounting Instructions for
Flight Sub Imprests at ANNEX A
200.165.30
Fatigue and Food. The need for adequate feeding facilities and the ability to
receive good quality nutrition is often overlooked when fatigue is considered. In certain susceptible
individuals, low blood sugar levels caused by insufficient food at key times may contribute to a
reduction in alertness, although most normal healthy people are able to maintain stable blood
sugar levels even if a meal is missed. Furthermore, there is evidence that high sugar content
drinks alone do not alleviate sleepiness caused by fatigue. As mentioned previously our bodies
are usually adjusted to be active during the day and to sleep at night, and the digestive system is
also controlled around this cycle such that it is far more efficient during the day and much less so
at night. Digestive juices (stomach acids and enzymes) are mainly secreted during the day;
therefore, food eaten at night will undergo slower digestion than during the day. Consumption of
foods with a low glycemic index (GI) is thought to release energy more slowly, which may be an
advantage to individuals working on a night shift.
200.165.31
Feeding Facilities. In order to ensure shift workers working non-regular hours
are adequately fed during a twenty four hour period, DHs should ensure that facilities are available
to provide personnel with a choice of hot and cold food.
200.165.32
Stimulants. Caffeine is the most widely recognised and used stimulant.
Caffeine has the effect of perking you up by blocking adenosine reception in the brain. Adenosine
can suppress nerve cell activity and may be involved in the sleep/wake cycle. Caffeine from drinks
(eg coffee) are usually absorbed within 45 minutes of consumption and the affects can last for up
to 6 hours. Therefore, caffeine consumption is not recommended close to periods of sleep. The
use of caffeine needs to be carefully managed as taking it too often increases the bodys tolerance,
therefore reducing the effect from the same quantity. Caffeine also needs to be used strategically
and a number of strategies to ensure maximum benefit are detailed below:
a.

Personnel should avoid caffeinated drinks/food when they are not tired.

b.
Avoid caffeinated drinks/food in the morning, as the body is waking up naturally and
will feel more awake as the morning progresses. Using caffeine to speed this process
simply increases an individuals tolerance to it. However, the exception to this is when
required to rise earlier than normal or in need of an extra boost.
c.

Avoid caffeinated drinks/food within 3 hours of bedtime.

d.

Awareness of how long caffeine takes to be absorbed and to take effect.

e.
Be aware how much caffeine you are consuming. Caffeine has a small diuretic effect
in people who do not use it regularly, and you will need to increase your water intake to
counter act this effect.
f.
Finally, whilst coffee is a stimulant and causes a temporarily increased level of
alertness, fatigue is symptomatic of its withdrawal.
7

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200.165.33
Hydration. The human body posses a sophisticated and highly effective system
for managing water needs. However, because military operations often require crews to wear
aircrew equipment that may limit body cooling, and may take place in hot environments or where
adequate water is not readily available, dehydration (relative inadequacy of body water stores) is
possible. Dehydration may also occur following exercise, and occasionally in relation to high levels
of caffeine intake. Sitting in hot aircraft on the ground for long periods of time, lengthy transport
times to aircraft, limited water intake due to hurry or simply concentrating on work and not drinking
enough water are all possible factors contributing to dehydration. It is generally accepted that a
loss of 2% of body weight (equivalent to 1.25 - 2 litres of fluid) will cause significant problems with
mental tasks, and it is thought that as little as 1% loss of body weight could also effect
performance. It is almost certain that lesser degrees of dehydration can increase ones
susceptibility to G-induced loss of consciousness (G-LOC). A common sense approach to
hydration is required because it is not desirable to drink so much water that the need to urinate in
flight becomes a problem. Drinking a great deal more water than is needed can cause an
imbalance in water/sodium balance, which can also have strongly detrimental effects. In general,
water provides adequate hydration but under certain environmental conditions additional salt
(electrolytes) may be required. During normal flying operations, base water intake on thirst and
urine colour (straw coloured). In situations of thermal stress, anticipate dehydration and drink
prior to thirst coming on. Crews of high performance aircraft should pay particularly attention to
drinking adequate amounts of water especially in hot conditions, and strenuous exercise before
flying should be avoided. Advice on specific operational/training circumstances (including need for
salt replacement) should be sought from a Flight Medical Officer.
200.165.34
Shift Work. It is vital that supervisors understand their shift system, in which our
personnel should be given sufficient time to sleep, rest and to have family and social time away
from work. A fatigue friendly environment equates to a normal routine Monday to Friday hours eg:
0800 1700 shift. Yet even allowing a shift pattern allowing personnel to finish by 2200 would still
provide satisfactory opportunity for sleep and rest without having to waken excessively early the
following day. However, whilst this provides sufficient time for sleep, there is little or no time for
socialising or spending time with families or friends thus leading to social isolation and depression,
both of which can lead to fatigue. Therefore, providing ample opportunity for balancing sleep,
social and family time should be taken into account when choosing a particular shift pattern. Shifts
should also have a definitive end of duty time, as the absence of a definitive end of duty time
creates uncertainty which can act as a stressor within the body that may lead to mental fatigue.
This is particularly key on some engineering night shifts where personnel commence duty at 1630
and have no definitive end of duty time. DHs should therefore ensure that for normal situations an
end of duty time is defined. Furthermore, DHs should ensure that their ADS/orders where fatigue
is covered includes maximum permissible consecutive duties and details mandatory rest periods.
These duties should clearly articulate the process for deviation away from the norm, where an
increased consecutive period is required for operational reasons.
200.165.35
Fatigue Management Strategies. Whilst the aim of a FRMS is to reduce fatigue
levels to as low as reasonably practicable (ALARP), achieving this goal involves management of
time available to sleep and awareness of the actual sleep obtained. It may not be possible to
completely eliminate fatigue from all working environments and supervisors should understand that
a certain amount of fatigue in the work place may be acceptable, provided the risks are identified
and managed. Management should make themselves familiar with Circadian lows, and should be
aware when these are likely to occur and manage their personnel. The tasks carried out during
these increased periods of fatigue should be managed carefully. Latent errors are failures of
organisation or design that may contribute to the occurrence of an incident. Management can
implement countermeasures as defences against latent errors. For example, once a shift plan is
established, the responsible managers should target the areas of highest fatigue and apply fatigue
management strategies to alleviate the opportunity for a fatigue-related incident to occur. The
main strategies to counteract the risk of fatigue-related errors include:

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a.
Ensuring that personnel are appropriately trained and understand their personal
limitations and are aware of strategies to increase alertness:

b.

c.

d.

(1)

Fatigue awareness and competency training.

(2)

Through-life fatigue training.

(3)

Training on maximising sleep and alertness.

(4)

Information regarding the impact of food and hydration on alertness.

(5)

The impact of physical activity.

(6)

The use of appropriate stimulants and usage.

(7)

Information for families on facilitating sleep at home.

Tasking less complex or less safety critical tasks at times of higher fatigue risk:
(1)

Where possible ensure high-risk tasks are conducted during the day.

(2)

Rotation of tasks.

(3)

Avoid mundane tasks during times of higher fatigue.

(4)

Avoid highly complex tasks at times of higher fatigue.

Increased checking to improve the likelihood of detecting errors:

(1)

Closer supervision on complex/demanding tasks.

(2)

Working in pairs or teams dependent on the task.

(3)

Task rotation.

Improving working environment that can also reduce the risks associated with fatigue:
(1)

Interaction with peers.

(2) Adequate facilities for breaks; including caf facilities or vending machines with
healthy snacks, caffeine drinks.

200.165.36

(3)

Napping facility (might be required for specific environments).

(4)

Suitable lighting and temperature control.

(5)

Awareness of those personnel that commute before/after shifts.

TRAINING

200.165.37
Initial Training/Education. Training is an essential component of Fatigue Risk
Management. On completion of initial training, personnel should understand the following:
a.

The theory science behind fatigue.

b.

RAF fatigue management policies and procedures.

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c.

The individuals responsibilities in managing fatigue.

d.
How to identify and manage risks associated with fatigue at both a personal and
organisational level.
e.
The management responsibility for decisions that influence sleep opportunities for
personnel and the available appropriate fatigue-reduction strategies.
Training records should be annotated with dates to reflect that training has been carried out JPA
(HF Trg).
200.165.38
Through Life Training. Fatigue training at each phase will be included as part of
the Human Factors. DH and STAR training will be covered in the DHASC and DASMC. Those
personnel that require post specific training by the MAA, such as Flying Supervisors, Flying
Authorisers and Flight Safety Officers Course will include elements of fatigue training.
200.165.39
Legacy Training. Those personnel that have missed either of the above training
courses are to ensure they make themselves conversant with the guidance within this document.
Furthermore, a Flight Safety DLP 8 will be created to capture fatigue management which will
provide further understanding. There is an aspiration to hold a bespoke fatigue management
course for STAR and duty holders who are not familiar with fatigue related management strategies.
200.165.40

FRMS COMMUNICATION AND PROMOTION

200.165.41
Communication. There is a requirement for ongoing communication to DHs
about activities and the safety performance of the FRMS, to maintain focus on the issue of fatigue
and encourage continuing commitment of all DHs. Types of communication will include: website,
email, newsletter, bulletins, seminars and periodic poster campaigns in strategic and operational
locations.
200.165.42
Promotion and Feedback. Routine review of fatigue-related hazards and
incidents will be fed to DHs via the Air Safety Governance meetings. If a serious fatigue-related
event occurs, it will be promulgated at the earliest opportunity to DHs. Trending of indentified
fatigue-related ASIMS reports will be highlighted in RAF Flight Safety publicity in order to
demonstrate the worth of reporting and to promote fatigue lessons identified. Feedback
mechanisms will include, but not be limited to ASIMS, Air Clues and Air Safety Notes.
200.165.43
Fatigue Monitoring. Whilst fatigue monitoring matures during the
implementation phase (1 Apr 12 31 Mar 13), a CAP TA chaired Fatigue Working Group (FWG)
will be held on a quarterly basis, with representation required from each ODH level, to ensure
progress against the FRMS.
200.165.44

CONTROLS AND TOOLS

Controls and Tools. Accountable managers should make themselves aware of some of the tools
that are available to manage fatigue. The controls and tools listed in this document are not
exhaustive, and managers should not be restricted to only those included herein. The tools listed
here are designed to facilitate fatigue management. It is for the DH to decide what would work
best for their AOR. Accountable managers should ensure that they understand and apply the most
appropriate action to combat fatigue in relation to the Fatigue Risk Trajectory described below and
detailed at Fig 2.

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Fig 2. Fatigue Risk Trajectory.

200.165.45
In order to manage and control fatigue, the Fatigue Risk Trajectory at Fig 2 is a
methodology proposed by Dawson and McCulloch (2005). A fatigue-related incident (FRI) or
accident is seen as only the final point of a longer causal chain of events of error trajectory. The
FRI is always preceded by a common sequence of event classifications that lead to the actual
incident. Thus, an FRI is always preceded by a fatigue-related error (FRE). Each FRE, in turn, will
be associated with an individual in a fatigued state, exhibiting fatigue-related symptoms or
behaviours.
200.165.46
Each of the four levels in error trajectory for an FRI provide the opportunity to
identify potential incidents and more importantly, the presence or absence of appropriate control
mechanisms. In common with other types of error, there will be many more potential than actual
incidents and that these could if monitored, provide a significant opportunity to identify fatiguerelated risk and to modify organisational processes prior to an actual FRI. Although the Fatigue
Risk Trajectory focuses predominantly on sleep, the system will aid DHs to identify the root causes
of many potential FRIs in a logical and consistent manner.
200.165.47
Controls are aimed at ensuring that work scheduling provides personnel with
sufficient sleep opportunities. To achieve this, consideration should be given to length and timing
of shifts and breaks, number of shifts worked consecutively and number of days off between shifts.
This should enable an approximate estimate of how much sleep personnel will obtain. It is also
important to access work schedules by examining specific aspects of the hours of work. Sleep
opportunity alone should not determine appropriate schedules even though it is generally the most
important factor. For example, although it is known that an early morning start will generally
produce higher fatigue levels; in certain circumstances a 0500 morning start may be more
appropriate than working under extremely hot and humid conditions in the afternoon. The overall
balance against risk needs to be understood.
This factors related approach reflects the risk-based approach of an intelligent SMS. Below are
some aspects of the level 1 of the Fatigue Risk Trajectory that should be used to assess sleep
opportunity and potential fatigue levels:

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a.
How many hours are worked per seven-day period? As total hours worked increases,
sleep opportunity decreases.
b.
What is the maximum shift length? As the length of a given shift increases, the
subsequent sleep opportunity decreases.
c.
What is the minimum length of time between shifts? A short break is defined as a
single sleep opportunity between subsequent work periods. It is typically a period of less
than 32 hours. As the break between shifts decreases so does the sleep opportunity.
d.
How many hours are worked between 2100 and 0900? This relates to late finishes,
early starts and night work. These will reduce night sleep opportunity and result in a
significant reduction in total sleep opportunity.
e. How often do personnel get a long break from work? A long break is defined as a
period of two night sleeps with a non-working day in-between. Long breaks typically
provide a significant opportunity to recover from sleep debt accumulated over a series of
shifts.
200.165.48 Table 2 provides an example of how the questions above can be quantified into a rule
system where fatigue scoring is used to identify potentially high fatigue-hazard areas.
Fatigue Likelihood Scoring Matrix for Work Schedules
Score

a) Total hours per 7 days

< 36 hours

36.1
43.9

44
47.9

48
54.9

55+

b) Maximum shift duration

< 8 hours

8.1 9.9

10
11.9

12
13.9

14+

c) Minimum short break duration

> 16 hours 15.9 13

12.9
10

9.9 8

<8

16.1
24

> 24

d) Maximum night work per 7 days

0 hours

0.1 8

8.1 16

e) Long break frequency

> 1 in
7 days

< 1 in
7 days

< 1 in
14 days

<1 in
< 1 in
21 days 28 days

Table 2. Fatigue Likelihood Scoring Matrix for Work Schedules

200.165.49 In Table 2, a 0900 to 1700 work week (5 days in a row) would produce a score of
zero. On the other hand, a work schedule of seven 12-hour night shifts (2100-0900), followed by
seven days off would produce a score of 21, which would be considered high 9 . Calculating a score
for a schedule would allow DH to quantify what they deem to be acceptable or unacceptable. For
example, a task may be given a lower score for highly complex or safety-critical work or for a high
environmental stress working environment (e.g. high humidity) than for less critical work in an air
conditioned environment. Initially, scores will be best estimates; however, as the understanding of
fatigue hazards improves through the collection of data on ASIMS reports, scores that show signs
of providing insufficient sleep opportunity should be reassessed. In order to assist in the matrix of
fatigue scoring RAF Flight Safety has derived the following levels as an indicator to assess fatigue
levels. This scale should be used as a guide to aid assessing potential fatigue risks.
a.
Low 0 6: Considered low risk related to the likelihood of a fatigue related error to
occur. This region would be the optimal operating environment for all tasks.

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b.
Medium 7 16: Considered a medium risk related to the likelihood of a fatigue
related error to occur. This region requires fatigue management, awareness and mitigation
strategies.
c.
High 17 26: Considered a high risk related to the likelihood of a fatigue related
error to occur. This region should be short duration where there is no other means to
achieve the task. Furthermore, increased awareness and management strategies need to
be adopted to mitigate against a fatigue related error. Extensive periods of operation in this
region are to be escalated up the chain of command to ensure ownership of the increased
risks associated with fatigue.
d.
Extremely High 27 40: Considered an extremely high risk related to the likelihood
of a fatigue related error to occur. This region should be avoided where possible. An
extensive understanding of fatigue management is required to manage persons within this
region. Escalation to the DH is recommended to ensure ownership and that a risk
assessment against the task has been carried out necessitating the operation in this region.
200.165.50 This fatigue scoring matrix does not explicitly take into account the effects of
cumulative fatigue. However, if you take into account the scoring over a rolling 28 day period you
will be able to average this out. Thereby establishing a score that would provide an indication on
the possible effects of cumulative fatigue over a 28 day period. For example; a shift pattern
working 12hr shifts between 2100-0900, 4 days/4 Off, 4 nights/4 off and so on would produce the
following scores: 1st Shift Score = 10, 2nd Shift Score = 18, 3rd Shift Score = 10 and 4th Shift Score
= 18. Whilst being on nights the score produces a score of 18, which is considered high but the
mitigation against this is that it is short lived and averaging over the 28 day period gives a score of
14 which is considered medium. This system allows DHs to understand where the increased
levels of fatigue are likely to occur. The fatigue scoring matrix can produce scores averaging 14
over a 28 day period where persons are not actually receiving a full day off, but do receive a period
of 24hrs off between shifts. Therefore, the fatigue scoring system needs to be taken in context and
the environment in which it is being used.
200.165.51 Prior Sleep and Wake Model (PSWM). The PSWM is another tool to identify
whether an individual is likely to be affected by fatigue, and can identify an individuals working
time prior to becoming fatigued. Figure 3 displays an example of the PSWM:
Start of duty
End of duty
Wake-up

23:00

06:00

23:00

Sleep

07:00

Sleep

23:00

07:00

Work

Sleep prior 24 Hrs [8Hrs]

Sleep prior 48 Hrs [15 Hrs]

Time awake [24Hrs]

If [24 Hrs] is more than [8 Hrs] + [15 Hrs] there is a significant increase in the
Likelihood of a fatigue-related error

Fig 3. Example of the Prior Sleep and Wake Model (PSWM)

200.165.52 In order to determine if a person is likely to be fatigued and to assess the required
degree of hazard control, a simple calculation can be performed on the amount of sleep and wake
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experienced in the 48 hours prior to commencing work. Fig 3 provides an example where the
periods of sleep or wake do not meet the criteria and there is a significant increase in the likelihood
of a fatigue-related error and the DH should implement an appropriate hazard control procedure for
the individual. It should be noted that the thresholds could vary as a function of fatigue-related risk
within a working area. For example, if a task has either a greater susceptibility of fatigue-related
error or there are significantly greater consequences of a fatigue-related error, the threshold values
may be adjusted to a more conservative level.
200.165.53
Fatigue Risk Tools Available. The following are examples of the tools available
to facilitate fatigue management, but the list is by no means exhaustive and there are a plethora of
industry tools available. It should also be noted that RAF Flight Safety does not endorse nor
recommend a specific tool. The following are some of the tools available:
a.
FAID Fatigue Audit InterDyne - is used to analyse planned or actual hours of work
from which indicative fatigue levels for individuals or groups can be determined. The results
can be used to help manage the risks associated with fatigue.
b.
FAST Fatigue Avoidance Scheduling Tool - FAST is a Windows program that allows
scientists, planners and schedulers to quantify the effects of various work-rest schedules on
human performance. It allows work and sleep data entry in graphic, symbolic (grid) and text
formats.
c.
BAM Boeing Alertness Model BAM is the mathematical modeling of Crew
Alertness to assess fitness for duty for flight deck and cabin crews. The BAM tool is
manufactured by Jeppesen and is an individual based crew alert application on smart
phones.
d.
Circadian A company that provides consulting, training, technology and information
to solve the challenges of the 24/7 workforce, including; optimizing shift schedules, fatigue
risk management systems and shift worker training.
200.165.54

RISK ASSESSMENT, HAZARD MANAGEMENT AND SAFETY ASSURANCE

200.165.55
Risk Assessments. As part of the RAF SMS, DHs are to ensure that they
robustly manage fatigue iaw this policy within their AOR. STAR teams and DH facing
organisations are to conduct routine analysis of fatigue-hazards and report any significant trends at
routine safety meetings and to RAF Flight Safety. All fatigue-related errors/incidents are to be
reported using ASIMS.
200.165.56
Hazard Management. DHs are to ensure that, within their AOR, they maintain
and document the three main types of processes for fatigue hazard identifies predictive, proactive
and reactive processes(see below). All of these processes gather various types of data to enable
continuous monitoring of fatigue risks covered within the FRMS. These processes enable the
ASGWG to make data-driven decisions that can be validated using scientific principles if required.
200.165.57
Predictive. In order to minimise potential future effects, predictive hazard
identification focuses on establishing crew schedules and shift working conditions that consider
factors known to affect sleep and fatigue. ICAO Annex 6, Part 1, Appendix 8 lists three possible
ways to do this:
a.
Experience of managers and supervisors. There will be a collective level of
experience from managers, supervisors, schedulers and personnel who are all key sources
of information for identifying aspects of a proposed roster that may cause increased fatigue
levels.
b.
Evidence based scheduling practices in accordance with fatigue reporting. The
value of experience can be enhanced when fatigue science is also applied in the building of
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schedules. This means considering factors such as the dynamics of sleep loss, recovery,
the circadian biological clock and the impact of workload on fatigue, along with operational
requirement. Since the effects of sleep loss and fatigue are cumulative, evidence based
rostering needs to address both one of trips/shifts and multiple duty periods. These
principles can be used by schedulers, managers or supervisors in fatigue hazard
identification, or by the FWG, to develop evidence-based rules on scheduling for specific
fleets. The following are examples based on fatigue science:
(1) The perfect shift for the human body is daytime duties with unrestricted sleep at
night. Any change to this status quo is a compromise.
(2) The circadian clock does not adapt fully to altered rosters such as night shifts.
However, it can adapt progressively to a new time zone, but full adaptation will
depend on how many time zones are being crossed.
(3) When a duty period overlaps a persons usual sleep time, it can be expected to
restrict sleep. Examples are early duty start times, late duty end times and night shift.
(4) Night shift also requires working through the time in the circadian body clock
cycle when self-regulated fatigue and mood are lowest, and additional effort is
required to maintain alertness and performance.
(5) Consecutive duties with restricted sleep will accumulate a sleep debt and
fatigue-related impairment will increase.
(6) In order to fully recover from sleep debt, personnel need a minimum of
two full nights sleep consecutively. The frequency of rest periods should be
related to the rate of accumulation of sleep debt.
c.
Bio-mathematical modelling. A range of bio-mathematical models are available
commercially and are marketed as tools for predicting fatigue hazards relating to schedules,
and some of these have been listed above. Used properly, these models can be a helpful
tool as part of the FRMS because it is hard to visualise the dynamic interactions between
sleep loss, and recovery and the circadian biological clock. To use models properly
requires some understanding of what they can and cannot predict. These bio-mathematical
tools should be validated against fatigue data from operations and schedules to ensure they
are robust and fit for purpose. It should be noted that whilst bio-mathematical modelling
offers some strong benefits, there are limitations.
d.

Current available models:

(1)

Predict individuals and group average fatigue levels.

(2) Does not take into account the impact of workload or personal and work-related
stressors that may affect fatigue levels.
(3) Cannot take into account the effects of personal or operational mitigation
strategies that may or may not be used by individuals, such as stimulants, exercise
and improved rest facilities.
(4) Does not predict the safety risk that fatigued personnel represent in a particular
operation or task.
200.165.58
The most effective and reliable method currently available to predict relative
fatigue levels is to compare likely fatigue hazards against schedules. Furthermore, biomathematical modelling should be used in conjunction with current fatigue data to validate and
confirm potential areas of fatigue hazards.
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200.165.59
Proactive. Proactive hazard identification processes focus on monitoring fatigue
levels in an operation or task. Fatigue-related impairment affects many skills and has multiple
causes, and there is no single measurement that gives a total picture of a persons current fatigue
level. The success of proactive fatigue processes depends largely on personnel reporting fatigue
through ASIMS. The willingness of personnel to continue to submit fatigue-related reports will also
reflect their confidence in the system will be detrimental by their understanding of the purpose of
the data collection, which is to improve safely. ICAO Annex 6, Part 1, Appendix 8 identifies five
possible methods of proactive fatigue hazard identification:
a.
Reporting of fatigue risks. Personnel reporting high fatigue levels or fatigue-related
performance issues are key to provide data to any Air Safety meeting about fatigue hazards
in day-to-day operations. A series of fatigue reports on a particular route/schedule/shift can
be a trigger for further investigation by the FWG.
b.
Personnel fatigue surveys. Personnel fatigue surveys can either be retrospective or
prospective surveys. Both approaches have their own merits; however, care should be taken
as to the periodicity of these surveys.
c.
Cross referencing fatigue related reports with Fight Data Monitoring (FDM).
Within commercial aviation there is considerable interest in establishing ways to link crew
member fatigue levels to FDM, particularly for approach and landings. The advantage of
using this type of data is that it is routinely collected and is relevant to flight safety. However,
there is difficulty in that a multitude of factors contribute to deviations from planned flight
parameters, which makes interpretation difficult. In order to use FDM as an indicator of crew
fatigue, it must be demonstrated that changes in FDM that are reliably linked to other
indicators of personal fatigue, such as sleep loss in the preceding 24 hrs.
d.
Cross referencing ASIMS with equivalent commercial Air Safety Reports (ASR)
and scientific research. There is a plethora of fatigue-related information available from
external safety databases, such as the ASR and MOR maintained by the CAA and airlines 10 .
Cross referencing some of the ASIMS data with these sources could be beneficial, especially
for multi-engine fleets.
e.
Analysis of planned versus actual hrs worked. The planning of schedules and
rosters based on fatigue as well as operational requirements permits predictive identification
of fatigue hazards. However, numerous unforeseen circumstances can cause changes to
planned schedules, i.e. weather, technical problems and personnel illness. Personnel fatigue
should relate to what is actually flown or shifts completed, not what was planned.
200.165.60
Given the primary importance of sleep loss and recovery in the dynamics of
personal fatigue, another valuable and commonly used method for proactive fatigue hazard
identification is sleep monitoring. Sleep can be monitored in a variety of ways, the simplest and
most cost effective method being where personnel complete a daily sleep diary before, during and
after trips/shifts. They are typically asked to record when they sleep and rate the quality of their
sleep, as soon as possible after waking. There are more objective measurements of sleep/wake
patterns which can be obtained by continuously monitoring movement whilst sleeping and
applications to assess this can be purchased commercially.
200.165.61
Reactive. The reactive processes are designed to identify the contribution of
personnel fatigue to reports and events. The aim is to identify how the effects of fatigue could have
been mitigated, and to reduce the likelihood of similar occurrences in the future. ICAO Annex 6,
Part 1, Appendix 8 identifies five examples of triggers for a reactive process:

10

ASR Air Safety Report, MOR Mandatory Occurrence Reporting Both civilian reporting.

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a. Fatigue Reports.
b. Confidential Reports.
c. Audit Reports.
d. Incidents.
e. Flight Data Monitoring Analysis.
200.165.62 Depending on the severity of the event, fatigue analysis should be undertaken by the
DH, FWG or a fatigue expert. Unfortunately, there is no simple test for fatigue-related impairment,
therefore, to establish that fatigue was a contributing factor in an event, it has to be shown that: the
person was probably in a fatigued state, the person took particular actions or decisions that were
causal in what went wrong and that those actions or decisions were consistent with the type of
behaviour expected of a fatigued person.
200.165.63
Safety Assurance. Fatigue risks and hazard assessments are integral to any
FRMS operation where the focus is on identifying fatigue hazards, assessing risks, putting in place
controls and mitigation strategies, and monitoring their effectiveness. The safety assurance aspect
of the FRMS forms another layer in the defences against fatigue-related risks. The FRMS safety
assurance processes monitor how effective the FRMS is functioning by carrying out the following:
a.

Check that FRMS is meeting the requirements defined within the FRMS policy.

b.

Check that FRMS is meeting regulatory requirements.

c.
Identify where changes in the operating environment have the potential to increase
fatigue risks. Identify areas for continuous improvement in the management of fatigue risk.
200.165.64

REPORTING, AUDIT AND REVIEW

200.165.65
Reporting. All personnel reporting any fatigue related hazard/observation,
incident or accident are to use ASIMS. Within ASIMS there are drop downs to guide completion of
all the relevant fields. Personnel should complete this report with due diligence, ensuring that all of
the fields are complete before submitting. RAF Flight Safety will conduct analysis of fatigue related
reports. However, DHs are to monitor ASIMS for fatigue related reports and conduct analysis within
their AOR. Reports that are of significant risk to Air Safety will be discussed at regular safety
meetings. Feedback on trends will be promulgated through RAF Flight Safety communications
and other mediums where appropriate.
200.165.66
Audit. Fatigue policies and guidance as part of the ADS within DHs areas will be
subject to audit in accordance with this FRMS. These checks will form part of the rolling audit
program.
200.165.67
Review. The FRMS will be reviewed annually in consultation with CAP (TA)
Fatigue Steering Group (FSG). CAP (TA) will chair and coordinate a Defence FSG and will be
responsible to discuss and identify trends and to provide guidance and mitigation on fatigue related
concerns across Defence.
200.165.68
Further Reading. The RAF Flight Safety FRMS has been developed in
conjunction with ICAO regulatory requirements and guidance from the FSG. The information within
this document, should provide the reader with sufficient knowledge to, manage and implement any
bespoke policy and guidance for their own ADS/local orders. For further information regarding
civilian good practice and current military policies are contained in the documents below:
a.
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CAP 371 The Avoidance of Fatigue in Aircrews.

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b.

MRP RA 2345 Aircrew Fatigue Management.

c.

2008DIN01-050 Guidance on the Working Time Regulations Service Personnel.

d.

AP100B-01 Order 1.9 - Fatigue Policy Guidance (Ground Crew).

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ANNEX A
To FRMS Policy
Dated: 1 Apr 12

EXTRACT FROM AIR COMMAND ACCOUNTING INSTRUCTIONS FOR FLIGHT SUB

IMPRESTS
BASIC REQUIREMENT
305. Accommodation is normally to be provided in accordance with the following guidelines which
are based on flight safety considerations and the care of RAF personnel:
a.
The standard of accommodation, room not necessarily facilities, should not be below
that considered acceptable in the UK.
b.
Room location should be such as to enable reasonably quiet, comfortable and
uninterrupted sleep by day or night.
c.
In extremes of climate, where Service accommodation would normally be heated or
air-conditioned, there should be adequate provision to heat or cool rooms as appropriate.
d.
Restaurant or messing facilities, for the provision of meals taken before and after
flights, should be readily accessible, though not necessarily in close proximity.
e.
The allocation of accommodation is not to be influenced by aircraft type, but such
factors as the nature of the next flying task, time on the ground and total crew duty time
inbound and planned outbound are to be considered, in order to reduce the unnecessary
booking of facilities.
SELECTION OF ACCOMMODATION
306. Service Accommodation. Service accommodation which meets the basic requirements is
to be used when available. Where necessary, rooms are to be shared, in accordance with the
criteria in para 312. Ground support personnel are to be accommodated in transit aircrew
accommodation when it is not required for aircrew. No public charges will be levied against
Service personnel on duty for accommodation in British Service messes, transit messes or
overseas Service-run transit hotels.
307. Foreign and Commonwealth Service Establishments. When transiting or staying at a
Foreign and Commonwealth Service Establishment, on-base accommodation is to be used when
available. Any accommodation charges are to be paid in the first instance by GPC,
notwithstanding this, centrally from the imprest, supported by receipts from the base authorities.
Where receipts are not obtainable, a detailed certificate of expenditure signed by the Captain must
be provided to support the FSI account.
308. Hotel Accommodation. Hotel accommodation may only be used when Service
accommodation is not available. The standard of such accommodation is to be that which would
normally be provided in Service accommodation.
When the use of hotel accommodation is necessary, a JPA F008 or F95 (FSI) is to be raised; this is
to be signed by the local Service authority. Only when there is no local Service authority are the
F663 and associated certificates sufficient.

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COLLOCATION OF CREW MEMBERS
309. Appropriate Service or hotel accommodation is to be used, in that order, even if such use
precludes the collocation of the entire crew. Where additional expense would be incurred by
collocating a crew, dispensation will be given only for operational standby reasons. Such
dispensation is to be sought, where possible in advance of the need, by the aircraft captain. The
need for such collocation is to be assessed by the Gp HQ, who are to issue authority for
collocation, either in the tasking signal (e.g. TRANSOP), or in an Operation Order, or by letter.
Should an aircraft captain elect to collocate his personnel without prior authority from Gp HQ, he is
to submit a Special Report in accordance with para 108.
310. Where sufficient on-base accommodation is available, and that accommodation satisfies the
basic requirements outlined in para 305, the collocated crew is to be accommodated on-base, in
accordance with para 306 or 307. However, where there is insufficient on-base accommodation,
the crew is to use hotel accommodation.
ALLOCATION OF ROOMS
311. Single Rooms. Senior officer crew members, aircraft captains and all commissioned and
non-commissioned members of the Flight Deck/Operational Crew and Staff Crew, as defined at
paras 302 and 303 are entitled to single rooms, depending on availability. The aircraft captain is
ultimately responsible for the allocation of single rooms and is to ensure that in all cases, flight
deck/operational crew take priority over support personnel.
312. Shared Rooms. Non-commissioned members of Support and Supernumerary Crews, as
defined at para 303 , are to share rooms. Notwithstanding this all sharing of rooms is to be in
accordance with the following constraints:
a.
Male and female passengers are not to share rooms, unless they are married to each
other.
b.

Officers are not to share rooms with Non Commissioned personnel.

c.

Warrant Officers and SNCOs are not to share rooms with Cpls and below.

d.

Members of separate crews when different rest and sleeping periods are envisaged.

e.

A maximum of 2 crew members are to be allocated to a room.

f.

Crew members are not to be required to share a bed.

313 . Air-Conditioned Accommodation. When the availability of air-conditioned accommodation

is limited, personnel are to be given priority in the following order:
a.

Crews on operational standby for Search and Rescue.

b.

Crews resting immediately before departure.

c.

Crews resting immediately after arrival.

In all cases, Flight Deck/Operational Crew, irrespective of rank, are to be given priority over
support personnel.

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REQUESTS FOR CHANGES OF RESERVATION
314. Aircraft captains may request changes in accommodation only when the basic requirements
of para 305 are not being met and the accommodation being offered is unsuitable or inadequate.
In the first instance, better accommodation within the same hotel should be sought. Aircraft
captains are to bear in mind that arbitrary changes of accommodation may cause loss of goodwill
between the RAF station and/or DHRS, handling agents and hoteliers, and might incur additional
cost. Captains are to report such changes by Special Report in accordance with para 108,
justifying their action.

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FS300.105
HUMAN FACTORS TRAINING POLICY

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300.105 HUMAN FACTORS TRAINING POLICY

REFERENCES:
A. MRP RA 1440
B. AP 3207 FS200.130.
C. The RAF Air Safety Management Plan
D. RAF FS 20100323 Human Factors and Maintenance Error Management System Foundation Train the Trainer Course

300.105.1

PURPOSE

300.105.2
Ref A details defence Human Factors (HF) policy. Ref B contains RAF
Aviation Error Management System (AEMS) policy. This section details the RAF strategy
for the implementation of training of HF and how it complements Error Management (EM)
training. This guidance is supplementary to the policy at Ref A and, as such, does not
countermand any regulation, or negate the requirement to comply with it. It will be
reviewed periodically and will be re-written after Defence AEMS (DAEMS) policy is
issued. Where possible, this policy will conform as closely as possible to that of the other
Services to ensure a common approach to, and understanding of, HF and EM.
300.105.3

APPLICABILITY

300.105.4
The policy, regulations and directives contained within this section apply to
all relevant RAF and MoD personnel under RAF Full Command and contracted personnel
as follows:
a.

HF and EM Foundation training is mandatory for all RAF personnel.

b.
Continuation training is mandatory for Relevant Personnel 2 as detailed at
Annex A; in DAEMS these relevant personnel are grouped into 'four worlds' 3 .
c.
Where relevant RAF personnel work for another organisation they are bound by
that organisation's training policy for the duration of that employment. They should
consider the HF policy, structures and training difference from RAF requirements and
consult the Chain of Command for guidance. On return to employment within the
RAF they should comply with this policy.
d.
This RAF training policy applies to all MoD Civilians who are employed in roles
that are the equivalent of, or related to, the RAF Branches and Trade Groups at
Annex A.
e.
Civilian contractors will operate in accordance with Civil Aviation Authority
(CAA) regulations and/or under explicit MOD contractual obligations. Para 30 of this
document details HF and EM training requirements for contractors employed by the
RAF.

Para 300.105.1 of Ref A states that, Commands shall determine Relevant Personnel with regard to: their proximity to aircraft
operations, maintenance and support; role and degree of responsibility and/or supervision exercised; exposure to risk; involvement in
HF training & development, D-FSOR report coding and analysis; consideration of any other relevant factor(s).
3

Aircrew, Maintenance, BM and Direct Support services.

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f.
Individuals of other Services (UK) and members of Foreign Armed Forces (eg:
exchange officers) on exchange to or permanently assigned to RAF aircraft,
equipment and systems or airfields must comply with the requirements of RAF HF
Training Policy. These individuals are required to complete the required levels of
RAF HF training prior to completion of the relevant platform (to include ATC/ABM
systems) OCU, training conversion programme or equivalent and may not, until
successful completion of such training, operate, maintain or supervise operation of
these systems outside of a formal course of training under direct supervision of an
HF-qualified individual. This requirement is not intended to apply to non-exchange
personnel operating or maintaining RAF systems under separate agreement (eg: US
military operation of RAF Reaper UAS by non-exchange personnel or the USAF/RAF
RC-135 Rivet Joint Programme).
g.
Where units of other Services operate from Airfields primarily operated by the
RAF, the respective RAF Stn Cdr must be assured that the non-RAF units comply
with RAF HF Trg Policy.
300.105.5.

RESPONSIBILITY

300.105.6
The Commander in Chief (CinC), Air Command is responsible for this
policy and is responsible for ensuring that the RAF complies fully with any HF and EM
policy, HF and EM training policy, regulations and directives contained in this document.
He will also ensure compliance with any policy published by the Military Aviation Authority
(MAA), specifically that contained in Ref. A. The management and assurance of this
compliance is delegated to the Inspector RAF Flight Safety.
300.105.7
All units are to keep a register of the training currency of all personnel and
report deficiencies to Gp HQs. It is the responsibility of all individuals, the unit chain of
command and gps to ensure that everyone has the ability to complete the necessary
training within the timelines specified in this document. The Defence Aviation HF Centre of
Excellence (DAHFCoE) at RAF Cranwell is responsible for training all HF Facilitators and
will train all HF Instructors and Examiners in due course. HQ AIR Command will ensure
that the necessary policy is available to direct training.
300.105.8

BACKGROUND

300.105.9
HF considers human performance and error. The RAF AEMS (the
RAF forerunner to DAEMS) considers HF as a fundamental part of EM, but HF is
also an individual topic outside pure EM. The performance aspect is aimed at
maximising end product and efficiency; error is addressed to reduce incidence. HF
training provides personnel with the practical understanding of HF and EM principles;
this is essential because human error continues to be cited as the main, or
contributory, cause of the majority of accidents and incidents in military and civilian
aviation. This training is a key enhancer of operational capability.
300.105.10
The success of AEMS and (in future) DAEMS is built upon a
foundation of appropriate HF and EM knowledge. The RAF is required to give all
personnel HF training to achieve this which is not merely a box-ticking exercise.
Training is conducted at the phased Training Schools and on stns/units across the
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RAF. The HF and EM training system is currently embryonic, however, work is under
way to ensure that the necessary structures are in place to achieve the desired levels
of training. This is entirely reliant on robust and proactive management and delivery
of HF and EM training across the whole RAF.
300.105.11
AEMS will align legacy Crew Resource Management (CRM)-based
HF training with the broader aspects of HF training and its application to managing
individual human error and, more importantly, organisation-induced error. It also
provides a common reporting format, taxonomy and investigative approach. The
principles are supported by an observable leadership commitment and support of a
'Just Culture 4 '. All activities undertaken under AEMS will meet the requirements of
the MAA-led DAEMS programme.
300.105.12

HF AND EM TRAINING OVERVIEW

300.105.13
HF and EM training is designed to provide the knowledge, skills and
attitude to effectively improve performance and reduce the frequency and severity of
human error in the workplace as part of the AEMS.
300.105.14
A high level HF Competency Framework (CF) is owned by the MAA and
maintained by OIC DAHFCoE 5 . The CF represents the HF Body of Knowledge (BoK), as
it is interpreted in the Defence aviation context, and provides the benchmark standard for
HF accreditation; it is included at AP7000. The CF also defines the benchmark standard
for the content of all HF Foundation and Continuation training
300.105.15
To be effective in reducing aviation accidents and incidents and managing
risk, HF and EM training needs to be through-life. It must improve knowledge and
awareness of HF and EM in the workplace and it must be effective in changing attitudes
and behaviours. HF and EM training is currently structured for personnel from the very
beginning of their RAF careers, however, there are many personnel who have already
started their careers who need to be trained with the same base knowledge. All personnel
must complete Foundation training and then all relevant personnel must complete
Continuation training on a rolling 2 year currency. Until everyone has gained the required
level of training, there are 2 parallel systems: current and legacy (see paras 12 and 13).
300.105.16
Units are able to maintain awareness of personnel compliance through
JPA. Ref D was sent by IFS to all stns; it mandated full training compliance by 2 years
from its issue. By Apr 12 all personnel should be recorded as trained and any deficiency is
to be captured by the relevant Unit Commander and monitored by ODH staff.
300.105.17

CURRENT HF AND EM TRAINING SYSTEM

300.105.18
The current system is applicable to all personnel joining the RAF from
when the system was established. HF and EM Training is categorised as Foundation or
Continuation training. Following the completion of Foundation training relevant personnel
are to complete regular Continuation training (at least every 2 years).
4

Described in Ref C and Section 200.135 of this document.

The CF will be issued after it is endorsed at the HF CEB in Jul 11. It will be included within the Military Aviation Authority Document Set
at the next amendment. In the interim, advice and guidance on the content of any RAF HF training should be sought from
RAF FS.

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a.
Phase 1 Initial Recruit Training. All RAF recruits are to receive a HF and EM
package (Module 1) during Phase 1 generic training. ,The training is to be consistent
with the Foundation Training standard laid down in AP7000 6 . Training at this level is
to provide recruits with a basic understanding of HF and EM concepts, taxonomy and
defences against error. Phase 1 Foundation training will last approximately a day
and successful completion will attract award of the following JPA competence, to be
actioned by respective Phase 1 admin staff:
Flight Safety|Human Factors Foundation Training|Joint
b.
Phase 2 Professional Training 7 . During Phase 2 professional training all
relevant personnel, detailed at Annex A, are to receive further HF and EM training 8 .
Relevant points are:
(1) HF and EM training is to include the day EM Foundation Module
(Module 2) with a total minimum duration of 2 training days 9 .
(2) If individual Training Sponsors cannot achieve the minimum training period
due to resource constraints they must notify their Gp HQ and RAF FS.
(3) Any degree of non-compliance is to be recorded in the Residual Training
Gap Statement (RTGS) and the associated risk held on a Group Risk Register.
(4) Phase 2 training establishments are to identify any shortfalls in their
training, after the issue of the CF, and inform units of personnel who have a
deficit in knowledge and what must be introduced to make good the deficit.
(5) The training complies with the requirements of Continuation training as
well as introducing Module 2. Successful completion will result in the award of
2 JPA competencies and resets the 2 yearly currency requirement:
Flight Safety|Human Factors Continuation Training|Joint
Flight Safety|Error Management Foundation Training|RAF 10
c.
Phase 3 Professional and/or Promotion Training. Some relevant personnel
receive further HF and EM training at Phase 3 training establishments. The training
is to meet the following requirements:

HF Competency Framework is to be included in AP7000 (22 (Trg) Gp-Generic Education Training Centre (GETC)) upon ratification by
the HFWG.

The ethos of this phase is to develop the basic principles from Phase 1 and to make them more relevant to particular Branches/Trade
Groups. Teaching of HF and EM at Phase 2 should be more facilitative in nature, should use examples from the appropriate functional
area and be tailored to the management level of the trainee concerned.
8

Currently, HF and EM training is conducted at a number of Phase 2 training schools and, until a TNA is conducted, is to be considered
to have met the requirements for award of the JPA competency at para 12b.
9

The duration of training can be extended in order to achieve compliance with the CF. Extensions may be implemented to meet civilian
legislation where applicable (e.g. ESARR 5 for ATC) and/or to achieve sufficient understanding of relevant HF and EM concepts.
10

Until the CF is issued, and respective revised HF and EM training packages are introduced, the current HF and EM modules delivered
are considered to be sufficient for the award of the JPA competencies.

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(1) Training is to be tailored to support the output of the training

establishment.
(2) Training is required to be a minimum of day facilitated training if it is to
attract the JPA competency detailed below.
(3) Qualifying training is to be recorded by the phase 3 staff as JPA
competency 11 :
Flight Safety|Human Factors Continuation Training|Joint
d.
Continuation Training 12 . HF Continuation training is to be delivered on stn as
follows:
(1)

Training is to be a minimum day of facilitated discussions.

(2) Group size is not to exceed 15 personnel to ensure adequate engagement

with all attendees.
(3) Continuation training discussions should include, but not be limited to,
military and civil aviation incidents and accidents to highlight practical HF and
EM issues applicable in the workplace of the attendees.
(4) Successful completion of Continuation training will attract the award of the
following JPA competence, which is valid for 2 years:
Flight Safety|Human Factors Continuation Training|Joint
e.
Continuation Training Waiver. Where relevant personnel fail to complete
Continuation training within a 2 year period of previous HF training their competence
will lapse and they will be subject to a review period. Under these circumstances the
following apply:
(1) Stn Cdrs (or equivalent) can authorise a waiver to cover a review period of
28 days for training to be prioritised on stn. If a lack of on-stn resources will
preclude training in this period, alternative assistance should be sought. SO2
AEMS at RAF Flight Safety can offer advice. All incidents of waivers will be
included in the quarterly HF report provided to the respective ODH and RAF
Flight Safety.
(2) Under exceptional circumstances units are to request a review extension
not exceeding 3 months from their respective Gp HQ, on behalf of the AOA, and
ensure training is prioritised for those individuals. The 3 month timeframe is
from the 2 year currency date, not additional to the Stn Cdr's 28 day waiver
period.
11

This is the same competency awarded from Continuation training which resets the 2 year currency. This will reduce the burden on
stns.
12

The aim is to generate attitude, belief and behavioural change in attendees and is not designed to follow a specific syllabus, or
framework. Effort is to be made to cover all of the main HF and EM concepts within the CF, but not at the expense of worthwhile,
relevant discussion in key areas. Thus, Continuation training is to be tailored to the audiences needs, reflecting major HF and EM
issues that have arisen in their respective workplace(s).

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(3) If training is not completed by the end of the 3 month review period
personnel are deemed to have lapsed currency. In this instance, or the
absence of a waiver, relevant personnel may not undertake aviation related
duties.
(4) Units are to report the number of personnel who are outside their 2 year
currency to Gp HQ who will assess resource issues and provide direction. The
frequency of reporting will be directed by individual gps.
(5) No action should be taken against any individual who has lapsed currency
if the organisation has not afforded the training opportunity.
300.105.19

LEGACY HF AND EM FOUNDATION TRAINING SYSTEM

300.105.20
The legacy system is applicable to all personnel in the RAF who did not
received HF and EM training during Phase 1 and 2 training.
a.
Foundation Training Legacy. A legacy training initiative exists to provide
appropriate HF and EM training to all relevant personnel who left phase 1 and 2
training prior to the introduction of HF and EM training into these areas.
(1) A RAF Flight Safety-approved HF and EM Foundation package has been
developed for delivery on stns.
(2) This package is the only approved HF and EM Foundation training for
legacy personnel.
(3) The training is only to be delivered by trainers who have completed the
approved Train the Trainer (TtT) course.
(4) The package consists of 2 modules, each lasting a day: Module 1
covers the fundamentals of HF and EM; Module 2 develops some of the key
concepts covered in Module 1, particularly, Just Culture and Error Reporting
and Investigation. All RAF personnel needing legacy Foundation training must
complete Module 1. Successful completion of Module 1 achieves the JPA
competency:
Flight Safety|Human Factors Foundation Training|Joint
b.
Module 2 must be completed by all Four Worlds personnel. Advice on any
Module 2 issues should be directed to SO2 AEMS, RAF Flight Safety. Successful
completion of Module 2 training will attract the award of the following JPA
competence:
Flight Safety|Error Management Foundation Training|RAF
c.
Unit HF and EM Training Coordinators 13 are to identify the number of personnel
not having completed Foundation training by the end of Mar 12 and report it to their
Gp HQ.
13

See 300.105.29 of this document

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300.105.21

HF TRAINER QUALIFICATIONS

300.105.22
In order to maintain consistent standards of training, content and delivery
across the RAF the following systems are used to train, qualify and track all personnel
delivering HF training.
a.
HF Foundation Instructors. An HF Instructors cse is currently being
developed by the DAHFCoE. It will qualify instructors to deliver HF training at
Phases 1, 2 and 3. Successful completion of the cse will attract a JPA competency,
which will be valid for 3 years. Revalidation will be by a standards check performed
by an HF Examiner. Further guidance will be issued once the cse is developed and
an ongoing TNA 14 is completed to direct how current instructors in these phases will
be trained.
b.
HF Foundation Trainers (Legacy). HF and EM Foundation training is only to
be delivered by personnel who have undertaken the approved HF and EM
Foundation TtT courses 15 .
c.
Defence HF Facilitators. HF and EM Continuation training is only to be
delivered by qualified Defence HF Facilitators, who have completed the Defence
Human Factors Facilitators Course 16 at DAHFCoE and have been awarded the
following JPA competency, lifed to 3 years:
Flight Safety|Human Factors Facilitator|Joint
d.
Defence HF Examiners 17 . Where practicable, every unit should have at least
1 HF Examiner and larger units should have at least 2. Personnel are to be
nominated by FLCs to undertake the duties of a Defence HF Examiner. They will be
awarded the JPA competency detailed below by the Senior HF Examiner, OIC
DAHFCoE. An HF Examiners Cse is being developed by the DAHFCoE and it is
expected that the input standard will dictate that the nominee is already a practising
HF Facilitator and an HF Instructor. Until the new HF and EM training structure is
mature, it is likely that some candidates (already HF Facilitators) will need to first
qualify as an instructor by completing the Defence Instructional Techniques Cse (DIT)
at DCTS, RAF Halton before completing the HF Instructors Cse and then the HF
Examiners Cse. RAF Flight Safety has final approval for all RAF applications to
become examiners. This competence is lifed to 3 years.
Flight Safety|Human Factors Examiner|Joint
300.105.23
14

HF AND EM TRAINING GOVERNANCE 18

Conducted by the DAHFCoE for the MAA.

15

Successful completion of the TtT course does not itself attract award of a JPA competency. However, as this is an interim solution,
to address a knowledge shortfall, the trainers are authorised to award the respective HF and EM Foundation JPA competencies.
16
Details on the Defence HF Facilitators Course are at Annex B and should be read in conjunction with AP7000 and guidance at Ref A.
17

By Sep 11, the DAHFCoE expects to have a 3 day Examiners cse coincidental with some Facilitators cses.

18

There is a clearly defined hierarchy of responsibility for the governance of HF and EM training, which flows from the Secretary of
States direction that, where legislation exists, the MOD is to be as good as or better than our civilian counterparts. The MAA is
empowered to set Defence policy, regulation and guidance for HF and EM training that all three Services are required to meet. In

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300.105.24
Stn and Gp HF and EM organisations are to be designed so that all HF
and EM structures, responsibilities and training are considered together and dealt with
cohesively, rather than as individual programmes.
300.105.25

Assurance activity at all levels will focus on:

a.

Training standardisation.

b.

The level of HF and EM awareness.

c.

Training and management policy, guidance and support.

d.
The RAF HF and EM training programme and related policy development
through feedback and increased knowledge.
e.
Management of HF and EM training activity, particularly progress toward
achieving Foundation and Continuation training compliance for all personnel within
the AOR.
300.105.26
RAF Flight Safety Responsibilities. RAF Flight Safety is available for
advice and guidance; the initial POC is SO3 Training. It will periodically audit ODH HF and
EM training processes, reporting through CinC to CAS on:
a.
The robustness of the HF and EM training structures and processes in place
across the ODHs.
b.

The degree of policy compliance and any pertinent resource limitations.

c.
The status of DDH and ODH HF/EM training, to be included in both quarterly
and annual reports, identifying non-complying units and reasons therefore.

300.105.27
AOA Responsibilities 19 . Each AOA has the following responsibilities wrt
HF and EM training:
a.
Each AOA is to ensure that all subordinate units are compliant with RAF HF and
EM training policy.

addition, as part of their assurance function, the MAA will periodically validate HF and EM training within the RAF to ensure it complies
with the Defence requirement and it has robust governance processes in place to monitor the effectiveness of RAF HF and EM training.
Assurance activity under this remit will be focused at the Cmd level, predominantly through RAF Flight Safety, and will seek proof of a
coherent end-to-end HF and EM assurance process at Cmd, Gp, Stn and Unit levels.
19

AOAs are to audit compliance as part of their standard assurance activities. They may produce further policy, regulation and
directives applicable to their AOR to supplement this policy, provided that they do not countermand anything.

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b.
ODH staffs are to collect the following HF and EM training information on both a
financial quarterly 20 and annual basis, or at any other time, as required by the AOA.
ODH staffs are to report collected information 21 on both a financial quarterly and
annual basis 22 to SO3 Training, RAF Flight Safety, Lancaster Block, HQ Air, RAF
High Wycombe, by not later than 15 days after the quarterly and annual closeout (ie:
15 Apr for the annual report):
(1) Numbers of Legacy Personnel within their AOR who have completed HF
and EM Foundation training against the total Statement of Trained Requirement
(SOTR).
(2) Numbers of Relevant Personnel (see Footnote 2 and Annex A) within their
AOR who have completed HF and EM Continuation training within the
mandated 2 year period against the total SOTR.
(3) Numbers of personnel, by stn (or equivalent 23 ), who are out of HF
currency and who hold a waiver.
(4) Predicted timescales to achieve full HF and EM training compliance. In
situations where circumstances change and predicted timescales will not be
met within respective quarters or annually, the DDH will notify the ODH and
RAF Flight Safety of the revised estimate and reasons for change in timescale
prior to the expiration of the quarter.
(5) Significant resource issues that are impacting on the ability of stns within
their AOR to achieve compliance with this policy.
(6) A summary of HF and EM training assurance activity conducted within the
reporting period, including any significant issues that have arisen.
(7) Feedback on the efficacy of RAF or Defence HF and EM training policy,
including suggestions for amendments or additions to the policy, as part of a
continuous improvement process.
(8) Feedback on the efficacy of all HF and EM training courses and products,
including suggestions for amendments or additions, as part of a continuous
improvement process.
(9)
300.105.28

A list of all the current stn-level HF Training Coordinators within their AOR.
HF AND EM TRAINING ORGANISATION ON STN

300.105.29
To ensure that effective HF and EM Foundation and Continuation training
is delivered across the relevant Branches and Trade Groups at stn level, each RAF stn, or
20

Periods 01 Jan to 31 Mar (inclusive), 01 Apr to 30 Jun, 01 Jul to 30 Sep and 01 Oct to 31 Dec.

21

JHC HQ is invited to report the same information

22

Or additionally, if there is significant change, non-compliance or requirement with any of the reportable information.

23

The term 'stn' is used throughout to refer to a RAF organisation directly responsible to 1, 2 and 22 (Trg) Gps and JHC HQ.

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unit, must have a robust HF and EM training organisation tasked with the day-to-day
management, delivery and performance monitoring of the HF and EM training programme.
300.105.30
Stns are to organise themselves 24 as necessary to achieve compliance
with this policy, or at the direction of their superior gp. Notwithstanding, each stn should
have a number of positions, with the following generic responsibilities:
a.
Stn HF and EM Training Coordinator 25 . The Stn HF and EM Training
Coordinator is the head of the stn HF and EM training organisation on behalf of the
Stn Cdr. He/she should be an SO2 level officer 26 and is responsible for ensurance of
the stn HF and EM training programme and assurance to the Stn Cdr. He/she is
responsible to the Stn Cdr for, but not limited to:
(1) Directing the activities of the Stn HF and EM training organisation to
achieve compliance with all relevant training policy, highlighting to the chain of
command where it is unachievable and/or any shortfalls in training and
resources.
(2) Reporting to the Stn Cdr on the efficacy of the stn HF and EM training
programme, including progress made toward achieving Foundation and
Continuation training compliance.
(3) Acting as the single POC for all HF and EM training matters for ODH and
RAF Flight Safety staffs.
(4) Liaising with RAF Flight Safety, ODH staff, and the DAHFCoE for guidance
on best practise and to feedback any training issues for Cmd action.
(5)

Having a permanent seat on the EM Steering Group.

(6) Conducting any HF and EM training committee/working group to feed the

EM Steering Group.
(7) Coordinating the stn publicity campaign to raise awareness of the aims
and details of the HF and EM training programme.
b.
SFSO. The SFSO should be a stn HF and EM SME. He/she should provide
practical SME advice to the command chain and the HF and EM Training Coordinator. Ideally he/she should be an HF Instructor and Examiner.
c.
Subordinate HF and EM Training Coordinators. Each wg, sqn, or other
subordinate stn unit is to nominate a HF and EM Training Coordinator responsible to
24

In terms of personnel, organisation and meetings.

25

As HF and EM training is a cross-stn requirement it is recommended that the stn training management SME, i.e. OC Force
Development Squadron (FDS), is the Stn HF and EM Training Coordinator. It is recognised that stn structures are diverse and, as such,
variations on this may be necessary. OC FDS (or other as determined) is responsible for HF and EM training. He/she should
establish, as a minimum, SME advice from the SFSO and SEMSCO on HF and EM matters and the STDO for training matters. The Stn
HF and EM Training Co-ordinator should complete Phase 1 and 2 trg (mandatory for all RAF pers) and the HFFC, irrespective of trade.
26

A SO3 level officer may be used if stn requirements dictate; this must be highlighted to gp.

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the Stn HF and EM Training Coordinator for the management, delivery and reporting
of HF and EM trg within their respective AOR. Their duties will be directed by the Stn
HF and EM Training Coordinator and should include:
(1) Acting as the single POC for all HF and EM training matters within their
respective AOR.
(2) Provision of reports to the Stn HF and EM Training Coordinator on
progress made toward achieving Foundation and Continuation training for all
relevant personnel within their respective AOR.
(3) Management and coordination of all Foundation and Continuation training
within their respective AOR.
(4) Identification and selection of suitable personnel to be trained as Defence
HF instructors or facilitators.
(5) Raising awareness of the aims and details of the HF and EM training
programme within their AOR.
d.
Stn Training Development Officer (or equivalent). The STDO is
responsible to the Stn HF and EM Training Coordinator for ensuring the standards of
delivery of HF and EM Foundation and Continuation training, plus other tasks as
directed by the Stn HF and EM Training Coordinator.
300.105.31
HF AND EM TRAINING OF CONTRACTORS. Contractors employed by
the MoD will be required to ensure that all of their employees have received 27 , and remain
current in, the appropriate HF and EM training mandated for them by the CAA. As such
the MoD is under no obligation to deliver training to these personnel. A RAF organisation
that is arranging a contract is to ensure that the contracted companies are compliant with
CAA regulations for HF and EM training of their employees. To this end, advice should be
sought from the relevant Commercial Department on the inclusion of clauses within
contracts with civilian companies which requires them to provide evidence that they are
fully compliant with all appropriate CAA regulations and will remain so for the duration of
the contract.
300.105.32
INDIVIDUAL CASES.
There are some organisations that, by
necessity, are granted exemptions or relaxations from the guidelines/orders in this
document. They are:
a. UAS/AEF. Policy for UAS and AEF is being developed with AOC 22 (Trg) Gp.
b. Aeromed. Temporary exclusion-guidance to be issued.
c. VGS. Temporary exclusion-guidance to be issued.
d. Diaspora. Temporary exclusion-guidance to be issued.

27

Training must be equal to or better than the RAF training.

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e. Other organisations. If any other organisation believes that it should be

exempted from any rules/guidance in this document it should contact SO3 Training
Policy at RAF Flight Safety 95221 3863/6666. RAF Flight Safety anticipates the
inclusion of additional organisations at its own direction, which will be notified in
updates to this policy and included herein at the next amendment.
300.105.33
CONTACTS. Any questions or comments regarding this training policy
should be directed to RAF Flight Safety, HQ AIR Command (email: Air-Flt Safety Training
SO3. Phone: 95221 3863 or 01494 493863).
Annexes:
A.

B.

HF and EM Training Requirement By Branch And Trade Group.

Defence HF Facilitators Course (HFFC).

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ANNEX A TO
300.105 HF TRAINING POLICY
HF AND EM TRAINING REQUIREMENT BY BRANCH AND TRADE GROUP
1.
The table below summarises the RAF Branches and Trade Groups identified as
Relevant Personnel as defined by MRP 1440(2) and, therefore, who require
additional HF and EM training as specified in this document.
2.
To support the delivery of Continuation training on stns it is the intent for an
appropriate level of training to be incorporated into each Branch/Trade Groups phased
professional training, with awareness if only certain personnel within the Branch/Trade
Group are engaged in aviation related duties. Future editions of this Annex will direct
requirements within phases for each Branch/Trade Group.
Branch/Trade Gp

Civilian Trg Requirement

Flying (All branches and NCA)

CAP 737 & JAR-OPS 1 Subpart N

Ops Support (ATC)

ESARR 5 & ECAC Common Core Content Guidelines

Ops Support (TG9)

ESARR 5 & ECAC Common Core Content Guidelines

Ops Support (ABM)

ESARR 5 & ECAC Common Core Content Guidelines

Ops Support (TG12)

ESARR 5 & ECAC Common Core Content Guidelines

Ops Support (Flight Ops)

JSP 551

Ops Support (Int) - Flying duties only

CAP 737 & JAR-OPS 1 Subpart N

Ops Support (TG11) - Flying duties only

CAP 737 & JAR-OPS 1 Subpart N

Ops Support (Firefighter)

JSP 551

Ops Support (RAF Police) Air Transport Security only

JSP 551

Engineer Officers

MIL 145

Engineer (TGs 1 and 2)

MIL 145

Engineer (TG 4)

MIL 145

Engineer (TG 5)

MIL 145

Medical Nursing Officer - Flying duties only

CAP 737 & JAR-OPS 1 Subpart N

Medical (RAF Medic) - Flying duties only

CAP 737 & JAR-OPS 1 Subpart N

Logistics (Mover)

MIL 145

Logistics (Supplier)

MIL 145

Logistics (Caterer) - Flying duties only

CAP 737 & JAR-OPS 1 Subpart N

Logistics (Driver)

MIL 145

Physical Education (Parachute Jump Instructor)

CAP 737 & JAR-OPS 1 Subpart N

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ANNEX B TO
300.105 HF TRAINING POLICY
DEFENCE HF FACILITATORS COURSE (HFFC)
INTRODUCTION
1.
The HFFC is delivered by the DAHFCoE, which is part of CFS at RAF Cranwell. The
DAHFCoE delivers around 20 HFFCs per annum on behalf of Defence. The approximate
allocation of places per cse is 8 RAF, 2 Army and 2 RN. The exact number of students
from the three Services allocated to each cse may vary, depending upon applications
received.
COURSE CONTENT
2.
The cse lasts 4 days and covers fundamental HF concepts, including
Communication, Decision Making, Situational Awareness, Perception, Leadership,
Personality etc. The primary focus of the cse is to train facilitators, not HF experts.
Students will be expected to have completed reading prior to the course to bolster their
knowledge of HF. It is expected that students will, as a minimum, have read one of the
following core HF documents before attending the course: CAAs CAP 737 Crew Resource
Management Manual and/or CAP 716 Aviation Maintenance Human Factors (both
available to download for free from the CAA website).
3.
During the cse students will be introduced to the art of facilitation and the skills
necessary to produce and deliver a successful facilitation session. The cse culminates
with students delivering 2 x 20 minute facilitated sessions on subjects allocated by the
staff. These sessions are usually delivered in pairs due to the time constraints on the cse
and they will be assessed to ensure the candidates have enough facilitation ability and HF
knowledge. Students will fail the cse if DAHFCoE staff are not confident that the student is
able to deliver valid and worthwhile HF Continuation training on stn 28 .
SELECTION OF PERSONNEL FOR THE HFFC
4.
When units select candidates it is worth considering how experienced they are
already as instructors. Facilitation requires the facilitator to be: at ease in his/her role at
the front of the room; assertive with students if required; able to think analytically on their
feet. Previous instructional experience is not enforced, however, those without it will have
a significantly steeper learning curve on the cse. Advice on the selection for facilitators
should be available from the Training Development Flt on stn and should be sought for
selecting potential facilitators; the DAHFCoE and RAF Flight Safety may also be contacted
for assistance. A web-based learning and assessment package is being developed that
will standardise the input and provide more relevant and coherent introductory material.
5.

The following selection criteria are also used:

28

A TNA conducted by the DAHFCoE has recommended a workplace assessment method of qualification, where the cse output is not
the qualification. Someone completing the cse will return to their unit to be mentored in role and certified competent by an HF
Examiner. The MAA is considering mandating this method in the future.

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a.

Rank of Sgt or above.

b.

At least 2 years service remaining.

c.

Instructor experience (see para 4).

d.

Have sufficient time and support to deliver HF Continuation trg on stn.

e.

Approved by the Stn HF and EM Training Coordinator.

f.
Have a distinct role in the stn HF and EM programme, rather than completing
the cse for interests sake.
6.
The Stn HF and EM Training Coordinator is to ensure that they, or an appropriate
other, brief a candidate fully on the content of the cse, including assessment requirements,
as well as their future role as a facilitator on stn. A student should commence the cse with
an understanding of what the cse entails and the context of their subsequent stn role after
successful completion.
APPLICATION PROCESS
7.
All applicants are to complete the attached Application Form before submitting it, via
the requisite signatories on stn, to SO3 Training, RAF Flight Safety (Air-Flt Safety Training
SO3) for FLC approval. Incomplete forms, particularly those without stn authorisation or
preferred course dates will be returned.
8.
SO3 Training, RAF Flight Safety will vet all applications to ensure that the correct
calibre of personnel is being recommended for the cse. Applications will then be
forwarded to DAHFCoE for loading onto an available cse. Thereafter, DAHFCoE staff will
manage all applications notifying successful applicants no later than 2 weeks before the
commencement of the cse
CONTACT DETAILS
9.
Personnel wishing to discuss the application process, or needing advice on the
selection of applicants, are to contact SO3 Training, RAF Flight Safety on Mil: 95221 3863
/ Civ: +44 1494 493863.
10. For other cse enquiries, particularly, those regarding the progress of an application
and cse allocations, personnel should contact the HFFC Cse Manager on Mil: 95751 8187
/ Civ: +44 1400 268187, or HFTS Admin on Mil 95751 8190 / Civ: +44 1400 268190.

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APPLICATION FOR DEFENCE HUMAN FACTORS FACILITATORS COURSES
APPLICANT: COMPLETE THE FORM IN FULL, INCLUDING LINE MANAGER AUTHORISATION AND FORWARD TO THE STN HF TRAINING COORDINATOR.
STN HF TRAINING COORDINATOR: SEND APPROVED APPLICATIONS TO RAF FLIGHT SAFETY, HQ AIR (Air-Flt Safety Training SO3).
INITIALS & SURNAME:

RANK:

SERVICE NUMBER:

BRANCH/TRADE:

CURRENT UNIT:

POST TITLE:

EMAIL:

CONTACT TEL NUMBER:

END OF TOUR DATE:

OUT OF SERVICE DATE:

COURSE DATES BID FOR:

1.

2.

3.

4.

AMPLIFYING REMARKS:
DETAILS OF ANY PREVIOUS INSTRUCTIONAL EXPERIENCE OR HF TRAINING

IN WHAT CAPACITY WILL YOU BE DELIVERING HF TRG ON YOUR UNIT?

(Including number of courses you will deliver, audience size and type etc)

LINE MANAGEMENT APPROVAL TO ATTEND COURSE

NAME:

RANK:

POST:

SIGNATURE:

STATION HF COORDINATORS APPROVAL TO ATTEND COURSE

I AUTHORISE THIS PERSON TO ATTEND FOR
THE FOLLOWING REASON(S):
NAME:

RANK:

POST:

SIGNATURE:

DATE:

HFTS ACTION (FOR ADMIN USE ONLY)

COURSE / RESERVE LIST(S) ALLOCATED TO:

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300.110 RAF FLIGHT SAFETY AWARDS
300.110.1

The RAF offers 2 awards to formally recognise flight safety excellence.

300.110.2
Flight Safety Award This is a means to reward individuals for conscientious
observation and alerting of potential dangers and hazards, and to encourage aviation safety
awareness and vigilance on the part of all personnel, both military and civilian and of all ranks. A
recommendation for a Flight Safety Award is to be raised in the following form:
a.

Part One

Citation raised by the Flight Commander or equivalent.

b.

Part Two

Remarks of Officer Commanding Sqn/Wg.

c.

Part Three

Remarks of Stn Cdr.

300.110.3
Parts 1 3 once complete are forwarded, through the DDH Flight Safety Officer
(FSO), to the relevant ODH Flight Safety staffs for consideration. If approved, a Flight Safety
Commendation Certificate is to be produced and forwarded to the DDH FSO for presentation to the
individual. The DDH FSO is to then forward a photograph of the recipient to RAF Flight Safety
along with the citation for inclusion in Flight Safety publicity material.
300.110.4
Green Endorsement A Green Endorsement is awarded to personnel who
display exceptional flying skill or judgement in handling an aircraft emergency or rescue situation.
300.100.5
Recommendations are made as for a Flight Safety Award, but indicating the
recommendation of a Green Endorsement. When the Green Endorsement has been approved a
certificate is to be produced by ODH staffs for presentation to the individual together with a further
certificate for inclusion in the individuals flying logbook. The DDH FSO is to then forward a
photograph of the recipient to RAF Flight Safety along with the citation for inclusion in Flight Safety
publicity material.
300.100.6 Templates for Flight Safety and Green Endorsement Award recommendations and the
relevant Flight Safety Commendation and Green Endorsement certificates are at Annex A and B.
300.110.7
Further information and guidance of Flight Safety Awards is available from RAF
Flight Safety at the following contact address, phone numbers or e mail.
Address:

Royal Air Force Flight Safety

HQ Air Command
Lancaster Block
RAF High Wycombe
Bucks
HP14 4UE

Tel:

Civ 01494496666

E Mail:

Air-RAF Flight Safety (MULTIUSER)

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Annex A to
Sect 300.110

To: SFSO

Unit Ref No: GOO/1234/5/Ops

RECOMMENDATION FOR A FLIGHT SAFETY AWARD

Name J Fictitious Rank SAC Service No A12345678 Sqn 15 Sqn, RAF Whats-itsName

Part 1. Citation
SAC Fictitious was performing the duties of Servicing Crewman, down route, 30 Feb 03 at
RAF Akrotiri on a VC10 aircraft. Despite all the other noises generated during aircraft
ground operations, he became aware of a faint hissing sound. Although neither the
Ground nor Air Engineer had observed or heard anything untoward during their aircraft
pre-flight walk-round checks, Cooper was particularly unremitting in his efforts to identify
the source of - what was to him - an out-of-place sound. Eventually he discovered that a
very small metallic foreign object had punctured the front left tyre of the right-hand
undercarriage. The Flight Safety implications of a tyre failing during the take-off roll, or in
the wheel well after gear retraction, are extremely serious. Through his diligence and
conscientious investigation I consider that Fictitious prevented a potentially serious
occurrence that could have lead to the loss of an aircraft. I strongly recommend that his
actions be formally recognised through a Flight Safety Award.

Original Signed

Signature:
Name / Rank: Junior Fg Off
Appt: J Eng O 1223 Sqn
Date: 12 Mar 03

Part 2. Remarks of OC Wg/Sqn

SAC Fictitious demonstrated a commendably high level of diligence whilst conducting this
flight servicing. It is clear that his actions stopped a chain of events that could have had
extremely serious consequences and I therefore strongly endorse this recommendation.

Original Signed
Signature:
Name / Rank: Senior Sqn Ldr
Appt: SEngO 1223 Sqn
Date: 17 Mar 03
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Part 3. Remarks of Station Commander

Fictitious persistence in tracking down this out of place sound prevented what might have
become a major accident. I, too, strongly endorse this recommendation.

Original Signed

Signature:
Rank: Gp Capt.
Station: RAF Whats-its-Name
Date: 1 Apr 03

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Annex B to
Sect 300.110
File Ref: 20120112-Gwint Commendation-U
12 Jan 12
AOC 1 Gp
RECOMMENDATION FOR A FLIGHT SAFETY COMMENDATION
Name and Initials: GWINT R

Rank:

SQN LDR

Trade/Branch: FLY(P)

PART 1. CITATION
On Nov 25, Sqn Ldr Rupert Gwint was the No4 of a Radar Trail recovering back to RAF Northolt.
As he decelerated, with both throttles at IDLE, he noted that the LH ENG indicated 72-83% NL
(significantly [35%] above the normal of 38% NL), with a TBT indication of 625C. The LH ENG
indicated 43% NL, also significantly above normal. At a height of 2000ft Straight and Level, and
with both throttles physically selected and checked at IDLE, the ac would not decelerate below
275kts. Unhelpfully, there were no associated captions, warnings, unusual noises or vibrations.
Gwint declared a PAN and sought guidance from the Typhoon Emergency Cards; however, he was
unable to ascertain whether the RH engine was in surge or not. The TBT reading pointed to a
Digital Engine Control Unit (DECU) partial loss of control, similar to a stuck throttle. However, with
no DECU caution, there was little evidence to support this diagnosis.
Gwint referred to the Locked-in Surge Guidance, descended and accelerated in order to regain
control of the engine. Despite an initial recovery of the engine parameters to normal, the engine
reset to its previously high power setting, therefore still presenting him with the challenge of landing
an aircraft that would not decelerate. Gwint considered shutting down the RH engine in order to
bring the aircrafts total thrust within manageable limits; however, this was discounted due to the
abnormal readings of the other engine.
Now short on fuel, Gwint was forced to recover the aircraft to RAF Brize Norton. He elected to set
the aircraft up for a Straight-in Approach, and then skillfully used a combination of airbrake and
manoeuvre to decelerate the aircraft. However, this still resulted in Gwints landing speed being
around 195kts - substantially above the normal of 150kts. To compensate for this, he correctly
deployed the Brake-chute, but was then faced with the residual thrust from both engines still being
too great to stop. Therefore, he shut-down the RH engine whilst skillfully keeping the aircraft
straight on the runway at 150kts. This procedure was essential to control the aircraft in these
circumstances, but is outside the scope of normal engine handling. After using judicious braking,
Gwint managed to stop the aircraft safely on the runway, thereby averting what could have been a
serious incident.
Faced with an ambiguous engine problem and becoming short of fuel at the end of a long and
challenging sortie, Gwint did exceptionally well to recover the aircraft to base without mishap. He
remained calm throughout a range of inputs and information from various sources; but with no textbook solution available, Gwint improvised, and thus maintained exceptional overall control of a
unique and confusing situation. His quick, logical thinking and exceptional piloting skill, in the face
of a problem not seen on Typhoon before, safeguarded a precious operational RAF aircraft. This
behaviour bestows great credit upon him, and is in keeping with the finest traditions of the RAF.
For this reason,
Sqn Ldr Rupert Gwint is nominated for a Green Endorsement to his Flying Log Book.
C R Cunningham
Wg Cdr
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OC XI Sqn
12 Jan 12
___________________________________________________________________

PART 2.

REMARKS OF OC SQN/WG

Commented above.
J Jones
Wg Cdr

PART 3 REMARKS OF STN CDR

In situations such as this, when faced with a unique set of airborne circumstances, the
opportunities for the situation to deteriorate are significant. Sqn Ldr Gwint demonstrated
exceptional airmanship, professional competence and a significant degree of leadership as he
processed information from a wide range of sources in order to develop a rational plan to recover
the aircraft. Sqn Ldr Gwint executed this plan flawlessly, demonstrating an exceptional level of
pure flying skills and reasoned, quick thinking as he executed the approach; importantly, he
maintained this throughout the landing phase correctly deciding to shut down an engine during roll
out thus preventing further damage. Recovering an aircraft under such novel circumstances
deserves an appropriate level of recognition and hence, this nomination for a Green Endorsement
has my strongest support.
M A Ballister
Gp Capt
Stn Cdr
RAF Coningsby
19 Jan 12

PART 4. REMARKS BY HQ 1 GP
This exceptional professionalism, logical thought, and disciplined execution of this complex and
unusual incident has undoubtedly prevented significant damage, injury and possibly loss of an
aircraft. Furthermore, the pilots based at RAF Coningsby are currently operating with less-thanideal flying hours per month due to low aircraft availability, which makes Gwints outstanding
handling of the emergency even more commendable. The nature of this emergency and
subsequent actions taken stand Gwint out from the plethora of other incident reports that HQ 1 Gp
receive, and thus this nomination has our strongest support.
W J Mountpelier
Gp Capt
Gp Capt Typhoon
30 Jan 12

PART 5. REMARKS BY AOC 1 GP

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Faced with a very challenging, yet undiagnosed situation, Gwint made calm, rational and correct
decisions to recover his aircraft safely. The award of a Green Endorsement is just reward for a job
well done.
U R DBAAZ
AVM
AOC
4 Feb 12

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SECTION 300.120 RAF ASSURANCE, PUBLICITY AND EDUCATION

300.120.1 STATION FLIGHT SAFETY POLICY

300.100.2. Station and Unit Flight Safety Officers. The SFSO should have direct access to the
station commander and to wing and squadron commanders on all aspects of flight safety, although
for day-to-day routine matters he would be responsible to the officer commanding operations wing
(or equivalent). In addition, the station commander should appoint an officer of the Engineer
branch to act as engineering wing FSO and each squadron or unit commander should appoint an
officer to be squadron or unit FSO. On larger stations, the appointment of an administrative wing
FSO should be considered. Immediately before or shortly after taking up their flight safety duties,
all FSOs must attend a FSOs course; applications should be made to the MAA. Exemplar TORs
for station and sqn FSOs are at Annex A.
300.120.3. Station Air Safety Steering Group. A vigorous flight safety committee with proper
status and executive authority can give effective impetus to flight safety on a station. A Station Air
Safety Steering Group is therefore to be established as a standing committee on all flying units and
on any non-flying units whose task is in direct support of flying operations. The station commander
should act as a chairman, with the SFSO as secretary. The composition of the committee is at the
discretion of the station commander, meetings should be held at least quarterly. Minutes of these
meetings should be kept for audit purposes and also forwarded to both Gp STAR and RAF Flt
Safety. SFSOs may find it desirable to hold informal meetings with wing, squadron and unit FSOs
between flight safety committee meetings. The committee should aim to establish and develop
firm courses of action, rather than simply serving as an administrative reviewing agency. With the
station commander as chairman, executive decisions can be taken immediately accident-provoking
situations are disclosed. It is imperative, however, that flight safety matters requiring urgent
attention are actioned immediately rather than deferred until the next scheduled meeting.
300.120.4
Station Flight Safety Cells. In order to supplement the work of the station flight
safety committee and deal exclusively with matters directly related to flying operations,
station commanders should consider the creation of a small flight safety cell consisting of the
SFSO and all UFSOs under the chairmanship of OC Operations Wing, his equivalent or the SFSO.
The cell should be convened monthly, or more frequently if required, to establish and sustain an
active approach to flight safety on all station units. To promote innovation it should encourage
initiatives, assess ideas and identify areas which require attention, where necessary co-opting
specialist station support and seeking advice, help and ideas from flight safety staffs elsewhere.
On routine matters it should ensure standardisation of reporting procedures and provide a ready
means for co-ordinating information and inter-unit flight safety surveys. Thus the cells aim is to
facilitate innovation and streamlined procedures whilst at the same time offering a strong flight
safety base able to respond quickly and efficiently to the demands of post-crash procedures and
investigations.
300.120.5
Flight Safety Surveys. One of the principal aims of Flight Safety is to discover
and remove potential causes of accidents. An effective method of achieving this is to conduct a
flight safety survey and to act upon the results. This involves making a detailed assessment of
many factors affecting, both directly and indirectly, the safe operation and servicing of aircraft and
then eliminating any shortcomings which may be revealed. Such a survey would be of particular
importance on a station that is reactivated, or where squadrons, aircraft types or roles are to be
changed. However, a station flight safety survey should also be carried out annually to ensure that
new causes of accidents are not allowed to arise or old ones to reappear.
300.120.6
Foreign Object Damage. Raf FOD prevention policy is detailed at Section
200.155 of this document. Station, squadron and particularly Engineering & Supply Wing FSOs
have a significant part to play through liaison with the station FOD prevention officer in ensuring
that the stations flight safety and FOD prevention programmes are closely co-ordinated.
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300.120.6
Bird Control. At all flying stations a bird control officer is to be appointed to
oversee the stations bird control activities. Certain stations are established with Service bird
control units (BCU), equipped to patrol the airfield in order to reduce the presence of birds, on the
airfield and on land immediately adjacent to the airfield, which pose a risk to aircraft. The BCU
should, by means of observation and survey, assess the local bird population, its habits and the
effect of aircraft flying at or near that station and take appropriate action to remove as far as
possible the risk to aircraft. The Service also employs contractors to provide bird control at many
UK RAF stations. In addition to carrying out BCU tasks, the companies are able to give
station commanders expert advice on bird problems and to identify other suitable measures to
control birds. Guidance on all bird control matters, together with environmental and airfield
grassland management advice, may be found in Air Traffic Management (ATM) 3000 Series
Regulatory Articles RA 3018(10) Aerodrome Bird Control) and MMATM Chap 18. Bird control
policy for the Royal Air Force is formulated by Air BM at HQ Air Cmd and affected through 1GP-BM
ATM Infra SO2.

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ANNEX A TO
AP 3207
FS 300.120
TERMS OF REFERENCE (TORS) FOR STATION FLIGHT SAFETY OFFICER/UNIT FLIGHT
SAFETY OFFICER1
References
A
B
C
D
E
F
G
H

RA 1200 Defence Air Safety Management

RA 1210 Management of Operating Risk
RA 1400 Flight Safety
RA 1410 Occurrence Reporting
RA 1420 Service Inquiries Convening Authority
RA 1430 Aircraft Accident Response & Post Crash Management
RA 1440 Flight Safety Training Requirements
AP 7002 The RAF Air Safety Management Plan

UNIT:
RANK/GRADE:
DATE LAST REVIEWED:
DATE OF NEXT REVIEW:
UNIT MISSION
1.

(Insert appropriate mission statement).

POST HOLDER'S TASKS AND RESPONSIBILITIES.

2.
As the Station Flight Safety Officer (SFSO) you are responsible to OC Ops Sqn for advising
the Stn Cdr, Wg, Sqn and Unit Cdrs on all aspects of flight safety. Your roles and responsibilities
are to be carried out iaw MRPs, and include:
3.

Primary Duties:
a.
Lead in the development and sustainment of the Air Safety Management System
(ASMS) iaw references C and H .
b.
Maintain and regularly review the RAF .. Air Safety Management Plan (ASMP)
iaw reference H.
c.
Advise the Stn Cdr, OC Ops Wg, and Stn executives on all matters relating to Flight
Safety iaw the above references in order to maintain the highest possible standards of safety
and risk awareness at RAF .. for all operations undertaken by ac operating from
RAF .
d.
Act as Stn LO and provide such assistance as is necessary to personnel conducting
Service and Unit-level Investigations at RAF.iaw Reference C and E.

(This template may also be used to create the TORS for the Deputy FSO)

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e.
Promote Air Safety awareness and a Just Culture at RAF iaw references C, G
and H.
f.
Lead in the development and sustainment of the Stn Aviation Error Management
System (AEMS) iaw references C, G and H
g.
Identify and coordinate the training requirements for Stn personnel in .SMS related
posts to ensure that all SMS positions are filled by SQEP iaw reference H. Also, maintain a
record of training requirements and training status of these personnel.
i.
Facilitate the delivery of Human Factors training across the Stn iaw references C, G
and H and maintain a record of the training in liaison with OC FD and the STDO. (The
coordinator on each stn may vary. The SFSO and OC FD are to organise, maintain and
record training in a coordinated manner).
j.
Act as Secretary for the Stn Air Safety Steering Group. Specifically, you should maintain
the Stn/Unit SMS Battle Rhythm (meeting schedule), and ensure that minutes/actions from
SMS meetings are recorded and tracked to completion.
k.
Deliver Flight Safety publicity and education, including the Arrivals Brief iaw reference
C, G and H.
l.

Plan and coordinate Stn Air Safety Trg Days.

m.

Manage the Stn Air Safety Risk Register.

n.
Liaise regularly with the SEMSCO (if one exists on stn) wrt Occurrence Investigations
and provide SME support to Occurrence Review Groups.
4.
Additional Duties. The TORs are further expanded to cover wider areas of responsibility
pertaining to Flight Safety duties at RAF ... In this respect you are to conduct regular visits
to all flying units on station (including visiting detachments) and associated supporting units to
examine, discuss and, where possible, improve Air Safety standards at all levels.
EQUAL OPPORTUNITIES AND DIVERSITY
.. .. ..
HEALTH AND SAFETY RESPONSIBILITIES
TRAINING AND DEVELOPMENT RESPONSIBILITIES

COMPETENCIES
5. The following competencies are required for the post:
a.

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Essential:
(1) MAA Flight Safety Officers Cse (FSOC).
(2) MAA Post Crash Management Incident Officers Cse (PCMIOC).
(3) ASIMS Version 2 trg (Defence Learning Portal).
(4) GETC HF Instructor and Facilitators Cse (at DHFTC).
(5) MAA Air Safety Management Systems Cse.

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b.

Desirable: Occurrence Investigator Cse; HF Examiners Cse.

c.

Mandatory: Human Factor (HF) and Error Management (EM) training.

APPRAISAL REPORTING CHAIN

1st Reporting Officer:
2nd Reporting Officer:
3rd Reporting Officer (if appropriate):
STAFF APPRAISAL RESPONSIBILITIES
.. .. . . .
AUTHENTICATION:
Name:
Rank:
Signature:
Post:

Date:

I acknowledge receipt of and have read and understood the above Terms of Reference. I
have retained a copy for my own reference.
Name:
Rank:
Signature:

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300.125

CURRENCY, COMPETENCY AND STANDARDISATION UNITS

300.125.1 INTRODUCTION
300.105.2
This chapter defines the relationship between currency and competency
and identifies the role of Standardisation Units in assuring and reporting that both meet
levels required for declared commitments.
300.125.3 AIM
300.125.4
Currency requirements shall be established to ensure that aircrew, ATC
and ABM personnel maintain the minimum acceptable competencies to meet declared
mission commitments for a particular platform or system. Minimum currency, however,
does not ensure an individuals competency is sufficient to reduce Risk to Life and to a
particular mission to both tolerable and As Low As Reasonably Practicable (ALARP). It is
the role of a fully resourced and independent Standardisation and Evaluation Unit
(StanEval) within each platform/system (or CFS as relates to 22 (Trg) Gp) to provide
assurance to the AOA and CAS via HQ Air that both units and individuals are sufficiently
competent to reduce the risk to the mission and to life to both tolerable and ALARP.
300.125.5

REQUIREMENT

300.125.6 Platform and Role Currency. AOAs will establish currency requirements for
each platform and crew position which ensure that minimum competencies required to
meet declared platform commitments are maintained.
300.125.7 Platform and Role Competency. AOAs will define minimal competencies for
each crew position on a particular platform. Additional competency requirements will be
defined for specialised missions and roles, with specific currency requirements set for such
missions and roles.
300.125.8
Standardisation and Evaluation Units. Fully-resourced and
independent StanEval Units will be established for each platform operated by an AOA.
These units are to review and report directly to respective AOA and RAF Flight Safety
sections on crew currency and competency levels no less than quarterly. An annual report
providing a full assessment of crew and individual currency and competency issues will be
prepared each year and submitted to respective AOA and RAF Flight Safety section. (See
Annex A for format).
300.125.9

OBJECTIVES

300.125.10

To fulfil the aim, certain objectives must be attained:

a.
AOAs must determine required crew competencies for declared platform
commitments.
b.

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Extant platform currency requirements should be examined to ensure they:

1.

Directly support required crew competencies and

2.

May be achieved with current manning and resource levels and

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3.

Support higher/external requirements (ie: NATO commitment).

c.
Where required competencies may not be sustained within current manning and
resource levels, shortfalls should be identified to higher authority.
c.
An independent StanEval Unit shall be established for each platform which will
provide reports directly to the AOA Safety and RAF Flight Safety Sections regards
crew currency and competency. 1
d.
Accumulated StanEval/CFS empirical evidence, Occurrence Reports and other
information should be examined regularly to identify hazardous trends, increase in
risk or loss of competency.
300.125.11

MEASURE OF CURRENCY

300.125.12 Crew currency will be measured in time (ie: hours per month) or events (ie: 2
refueling joins per month) or a combination of both.
300.125.13 Time Currency. Currency requirements measured in time must be drafted to
ensure that they provide a realistic measure of those activities that indicate an individuals
level of competency. (Examples: A pilot may only claim currency time in situations where
he is actually performing flying duties in his aircrew role. Mission crew may not claim
currency time for transit flights where their mission equipment is not in use.)
300.125.14 Event Currency. Currency requirements measured by event must be
drafted to ensure the events are directly associated with the core competencies associated
with an individuals crew role. They must be specifically defined and objectively
identifiable by the outside observer, with a clear beginning and end of each event (ie:
asymmetric approach and landing for a pilot must define at what point he takes control of
the aircraft, at what point the simulated asymmetric procedure begins and what point it
successfully terminates). Caution should be used regards event-based currency to ensure
that multiple crew do not slice up a particular sortie to such an extent as to erode the
effectiveness of the training events.
300.125.15 Experience Offset Currency. Analysis of aviation incidents across Defence
and in the civil aviation world indicates a direct correlation between an individuals depth of
experience with a particular platform and a corresponding reduction in Flight Safety
occurrences. ODH and DDHs may consider establishing variable currency requirements
based on an individuals experience and currency on a platform. In all cases, Experience
Offset Currency must be specifically authorised by the ODH. The use of Experience
Offset Currency, particularly on an hour-limited fleet or system, ensures that maximum live
training opportunities are made available to the less experienced crew, who are
statistically most likely to be involved in an air incident. In establishing Experience Offset
Currency, consideration should be given to:
a.
The length of experience and present period of currency of the individual to be
given experience offset.

The RAF operates several platforms as small bespoke flying units where OCU and StanEval personnel are found within the operational/training
flying unit. Whilst not optimal, it is not seen as reasonably practicable that such platforms establish separate StanEval units. In addition, CFS will act
as the primary standardisation unit for 22 (Trg) Gp flying units and as a secondary assurance level for 1 and 2 Gp platform OCU instructors.

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b.
An individuals performance in the air as formally assessed by the unit
leadership, StanEval and/or CFS.
c.
An individuals period of time away from the flying role due to posting, medical
downgrade or other factors. Under no circumstance should an individual be
considered for Experience Offset Currency within their first six months of returning to
the flying role from a long-term (greater than 6 months) posting away from the
platform/system or until their first successful annual recurring StanEval check.
d.
An individual being considered for Experience Offset Currency should receive
the endorsement of the platform StanEval unit.
e.
Consideration should be given to require additional simulator currency events
for individuals granted experience offset.
300.125.16
Air Warfare Centre Experience Offset Currency. The Air Warfare
Centre holds a limited number of posts occupied by personnel who may operate under a
modified form of Experience Offset Currency. As these individuals do not directly fill
operational or OCU training roles, the Commandant, Air Warfare Centre, may set forth
modified provisions for Experience Offset Currency, taking into consideration the
provisions of this section to the maximum extent practicable.
300.125.17
Effect of Section on ATC/ABM Personnel. Whilst the intent of this
section may be relevant to ATC and ABM personnel, 1 Gp-BM/SM will publish separate
definitive currency/competency and StanEval requirements in Section 400 of this
document 2 .
300.125.18
Effect of Section on Engineering Personnel. The MAA has set forth a
requirement that the RAF employ Suitably Qualified Engineering Personnel (SQEP) on
RAF-operated platforms. Whilst the currency, competencies and standardisation of
engineering personnel will be assured by the MAA and appropriate Duty Holders, this
section is not intended to apply to the SQEP requirement.
300.125.19

REVIEW OF CURRENCY STANDARDS

300.125.20
StanEval/CFS sections shall regularly review currency requirements and
policies set per platform, and with consultation of the appropriate AOA, shall publish
revised currency requirements to reflect changes in equipment, manning levels and
operational tasking. This review should be conducted no less frequently than once every
two years.

2
ATM/ABM personnel permanently assigned to a flying role on RAF aircraft, ie E-3D Sentry controllers, will be subject to the provisions of Section
300.135 in its entirety and such provisions of Section 400 as 1 Gp-BM/SM deem applicable.

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AP3207
ANNEX A TO
300.125 CURRENCY,
COMPETENCY AND
STANDARDISATION UNITS
STANDARDS QUARTERLY/ANNUAL REPORT FORMAT 3
File Reference
Date
Addressee(s) (Minimum: RAF Flight Safety, AOC x Gp via x Gp STAR)
RAF XXXXXX/CFS QUARTERLY/ANNUAL STANEVAL REPORT FOR PERIOD ENDING
XXXXXXXX
1.
During the period of XXXXXX to XXXXXX, the RAF XXXXXXXXX Standardisation Unit
conducted XXX (number) of standardisation checks on (aircrew/ATC/ABM/movements/Ops
Spt personnel). Of these checks, XX (number) were scheduled and XX (number) were NoNotice. Overall, XX (number) resulted in Average/Above Average results and XX (number)
resulted in below Below Average (unsatisfactory) results.
2.
The number of Below Average (unsatisfactory) results for the period represents an
overall XX% increase/decrease from the preceding quarter/year for all combined crew
positions. By crew positions, the breakdown, per platform, is as follows:
C-17, 99 Sqn (ie).
a. First Pilot
% increase/decrease, with major areas of difficulty/failure being:
______________________________________________________.
b. Co-Pilot
% increase/decrease, with major areas of difficulty/failure being:
______________________________________________________.
c. Loadmaster
% increase/decrease, with major areas of difficulty/failure being:
______________________________________________________.
3.
StanEval (CFS) checks for (Unit/Stn) indicate currency requirements were not met by
XX (number) individuals and waivers were required. Crew positions requiring waivers this
period were:
a.

First Pilot

# waivers for (ie: boom refuelling currency), etc.

4.
StanEval (CFS) assesses there is/is not a need for a change in currency/competency
requirements for the following positions. (Include rationale when recommending change).
5.
StanEval (CFS) recommends that the DDH/ODH consider (state
recommendations/issues to achieve minimum competency requirements to achieve the
platforms established or actual operational role).
Signature Block
Annex(es)

The reported submitted to the ODH/RAF Flight Safety should follow the order of this example. However, it may be necessary to include
information via annexes and tabs for simplicity, rather than attempting to incorporate crew position breakdowns into the body of the report. This may
be done in accordance with the Defence Writing Guide (JSP101).

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