Reports on Red Arrows and Flt Lt Cunningham's death

[green granite]

The inquest, in Lincoln, heard that Flt Lt Cunningham had completed ground safety checks when the ejector seat of his Hawk jet was deployed.

The main parachute did not deploy and the pilot did not become separated from his seat during the incident, the hearing was told. He landed on the ground still strapped into his seat.

An ambulance was called and Flt Lt Cunningham was taken to Lincoln County Hospital where he was confirmed dead in the A&E at 12.14pm.

A full investigation into how the ejector seat deployed is being carried out and further tests are being done, the inquest heard.

A post-mortem examination gave the cause of death as multiple injuries due to a fall from height following ejection from an aircraft. Toxicology tests were negative.

Det Supt Shaun West said Lincolnshire Police were preparing a file for the coroner to look into two critical questions:why the ejector seat activated; and why the parachute mechanism did not work.

Full article: Red Arrows pilot 'killed when parachute failed' - Telegraph (http://www.telegraph.co.uk/news/uknews/defence/8906375/Red-Arrows-pilot-killed-when-parachute-failed.html)

[PPRuNe Pop]

Red Arrows pilot Sean James Cunningham died of multiple injuries in ejection accident | Mail Online (http://www.dailymail.co.uk/news/article-2064677/Red-Arrows-pilot-Sean-James-Cunningham-died-multiple-injuries-ejection-accident.html)

[Wholigan]

Right .... these 2 threads are now merged and it would be really nice if people stuck to the topic at hand.

[Mandator]

Hope I don't get into trouble with this:

From the Martin Baker website:

RAF Red Arrows Incident on 8th November 2011

On 8th November, there was a fatal accident involving the Red Arrows Hawk aircraft XX177 following the ejection of a Mk10B seat.

We have had the opportunity to examine the seat and, while not wishing to pre-empt the outcome of the investigation currently underway, are satisfied that neither a mechanical nor a design fault were to blame for the fatality.

We welcome the opportunity to assist the Lincolnshire Police and the Military Air Accident Investigation Board in identifying the causes of this tragic accident

In the meantime, our thoughts and prayers are with the family and friends of Flight Lieutenant Sean Cunningham who lost his life in this accident.


See here:


Martin Baker - Press Release (http://www.martin-baker.com/getdoc/613a0e91-0e5b-4f15-84aa-8ebff5f43a5e/Press-Releases.aspx)

[airborne_artist]

You would imagine that MB would not be releasing that kind of info into the public domain until all public and MoD enquiries were complete.

[tidewatcher]

Maybe this thread could go on hold until next week for the family and friends sake?

[Clearedtoroll]

while not wishing to pre-empt the outcome of the investigation currently underway, are satisfied that neither a mechanical nor a design fault were to blame for the fatality

On the contrary, it seems pre-empting the outcome of the investigation is exactly the intention. Even then, the selective use of words suggests hedging of bets... Electrical fault? Related systems fault? Etc, etc. So basically it claims a lot and says little. I wouldn't draw any conclusions from this.

[NigelOnDraft]

On the contrary, it seems pre-empting the outcome of the investigation is exactly the intention. Even then, the selective use of words suggests hedging of bets... Electrical fault? Related systems fault? Etc, etc. So basically it claims a lot and says little. I wouldn't draw any conclusions from this.I don't think you need to draw any "conclusions" from it, but doubt it is anything other than basically correct and informative, particularly if you were, say, a non-UK Mk10 operator.

The CAA MPD was far more revealing in technical detail, and told a story in it's own right.

Electrical fault?Ummmm, where do you draw that from? Unsure of any of the Seat/Canopy system/operation that has anything to do with Electrics :rolleyes:

NoD

[Mach Two]

There is, but it goes the other way to the IFF. And the gas pipes are a one way system, so the IFF won't fire the seat, if you see what I mean.

Do remember that this seat has been flown for (easily) hundreds of thousands of hours and saved MANY lives - I think I have over 2000 hrs in it. This is a very unusual incident and I think we'll have to wait for a finding.

I would say that this, and other associated threads, have brought forth a HUGE amount of knowledge about the Mk10B, so thank you all. But, we haven't come up with any answers. Let the investigations do their work now.

[wokkamate]

Why is everyone on here always so reticent to discuss possible outcomes to incidents or accidents? This is a RUMOUR network after all. My heart and thoughts go out to Flt Lt Cunninghams family, but life does go on and the discussion that occurs here is usually thought provoking, relevant and interesting. What is discussed here is not the results of an official enquiry (which the MAAIB will post sometime next decade......), but is an unofficial way for 'experts' to speculate - and there's nowt wrong wi that!

So I say, let the people talk!

Just my 2 pence worth.......

[Bismark]

No one has mentioned pins..

[Mach Two]

Apparently safety checks were done and he was strapped to the seat.

[Airborne Aircrew]

I'll pre-empt this by saying I know bugger all about bang seats but it was my understanding that once the seat leaves it's rail the deployment of drogues/parachutes and seat separation etc. is all automated and "foolproof".

If that is the case then how could MB claim there's no failure in the seat? Reports seem to say there was no seat separation or drogue/parachute deployment. I can understand how they might be able to "get away" with saying it's not a fault of the seat that fired the it but after it's off the rail surely it's all MB...

[Twon]

AA,

Without wishing to speculate too much also, you mention that the process is automated but this process does rely on all the pins being removed, chutes being packed correctly and a host of other human interventions prior to and during the use of the seat. This is not to say that I think anyone at the Reds is at fault but the MB statement almost asks you to draw that conclusion!

[Trash 'n' Navs]

completed ground safety checks

Not sat on the 10B, do they include removal of the pins? Or does that come later (ORA)? IMHO, with the parachute failing to deploy, it raises the prospect that the pins were still in.



neither a mechanical nor a design fault were to blame

So are they suggesting command activated? What about servicing - could a mistake during servicing affect the plumbing enough to lead to inadvertant activation?

:(

[VinRouge]

Here is one for you. Is it possible to activate the seat firing mechanism with the pins in IF the seat firing sear directly under the pin is jolted, say catching on an item of clothing? From tin can days (not 10b seat), i remember a check under the seat to make sure a connection was made. If this connection were pulled for whatever reason, would the seat fire?

I dont mean to hijack the thread, i am interested for personal reasons whether other areas of the seat could cause a firing with the pins in is all.

[formertonkaplum]

Now my experience is the MK10 on Tornado.

But

What if the Static rod to the Drogue was not connected / reset correctly / or pinned to the anchor on the main gun correctly?

From my recollection, there would be no drouge deployment and as the inflated drogues withdraw it, no main para deployment regardless of Barostat operation to release harness and open scissor shackle.




Ultimately this is a tragic situation for all that are connected to it. The loss reminds us all the fragility of life but please also remember, there are some engineers in the equation as well. Those who installed and inspected the installation of that seat, I would imagine will be inconsolable. From my experience, Plumbers take immense pride and care with seat work; I know I did and the professional let alone the emotional hurt those guys will currently be experiencing will be unimaginable by most.


As for how / why the Seat was initiated I think only the board with all the facts have a chance to determine.

[BOAC]

Are we aware of any BoI reports on this or the previous crash?

[John Blakeley]

Formertonkaplum,

I cannot now remember what Mk of seat it was in the RAF's Buccaneer, but I was the (very) junior engineering member of the BoI which investigated the loss of 12 Sqn Buccaneer XN 978 at the run-in to the Paris Air Show in Jun 1971, and during his very low level ejection the pilot was lucky enough to survive the circumstances you postulate ie the static rod to the drogue gun had become disconnected and the drogue had not fired - everything else worked, and he went into the fireball with a partially deploying main chute and the seat still attached, via the unfired drogue gun, to the top of the canopy. The fireball kicked him back into the air and gave him the main chute (albeit with the chute and his flying clothing somewhat singed if I recall correctly) and he was then injured in the ribs as the seat came back across the canopy and hit him just before he landed on the edge of the fireball. His navigator ejected at low level successfully and normally. As you might imagine there was a great deal of interest from MB and the Command ejection seat specialists (I was an electrical specialist so not too much help) but if I remember correctly this was then the only seat installation where the pin attaching the drogue gun static line was mounted fore and aft rather than transversely, and I believe the installation was then modified. There were other seat issues as well eg it had been signed as being installed to the incorrect SP (the right one was, if I remember correctly still in course of issue) but these were not seen as directly relevavant to the instalation problem.

Somewhat ironically the same pilot had had his navigator eject on the runway at Karup some 3 weeks earlier, and he told the Paris BoI that when he went back after that incident to check the aircraft for safety he found this pin missing on his (unused) seat. At the time he had thought this was a special RDAF safety precaution (although it actually left the installation in a more dangerous condition) but it did bear out the fact that we were happy that he had indeed checked the pin was there on XN 978 before flight.

Whether any of this has any relevance to the main purpose of this thread, other than to confirm there have been incidents and accidents where the drogue gun has not worked "as advertised" I would not know - others with more knowledge may care to comment.

To complete this story though the second luckiest man on the planet was the gendarme who helped carry the pilot's seat into the guarded crash site through thick scrub and tree branches (they crashed in woodland near Compiegne) with the static rod dangling down and a live drogue gun pointing at his stomach. The drogue gun was still live when we got there the next day.

The rumours that although neither the pilot nor the navigator had planned on landing in France they returned witha bottle and 200 on the casevac Hercules later on the afternoon of the crash were to the best of my knowledge true - aircrew are obviously very good at making the best of the bad job!

Finally we had to do the BoI twice as the AOC did not like some thinly veiled critiscim in the BoI's findings of the pressure he had applied to the crew to do better - apparently the day before the Victor had appeaerd at the Show with the Lightning plugged in and the Buccaneer "chasing" the hose, and the pilot had commented to the BoI about this pressure. We had new aircrew on the second BoI, and I got a second visit to Paris! It does show though that comments on other threads concerning the need for an independence of the military investigation system from the chain of command are not without foundation - at least at that time anyway!

[Courtney Mil]

JB,

Buccanneer was Mk 6.

My last 6 months in the RAF were spent as the president of a BoI. The AOC didn't like our initial findings and spent 45 minutes screaming at me down the phone, telling what findings he wanted me to come up with. I'm pleased to say that I stood my ground. But it may have been harder for others - perhaps those with more of a flickering career caption than I - not to be swayed.

[cynical hat] Independant? I think not. Especially if there is likely to be any criticism of the convening officer of his mates. [/cynical hat]

[jindabyne]

CM

Likewise, I was a BoI President who was given grief by my SASO (not the AOC) to come up with HIS finding. I didn't, and the crew were given the benefit of the doubt (as in the Chinook affair). Not a popular Wg Cdr, but I didn't give a toss!

[soddim]

In the mid-60's I was a member of an accident board that found the AOC negligent - those findings only lasted until the AOC read them!

[dervish]

I think the last few posts have summarised the Mull of Kintyre case very well!

[Mach Two]

Dervish,

Agreed. I think we're starting to form a picture here. It looks like AOCs trying to influence the BOI is more common that I, for one, had realized. I'm impressed that those involved were able to resist being swayed. Well done.

[NutLoose]

There was a Jag in Germany where the shackle in the headrest for the drogue was found not to be connected, everyone was interviewed by the SIB, but I do not think the cause was ever found, so even if in that case the drogue deployed the main chute wouldn't.

[spottyemm]

Any update on this BoI?

[teeteringhead]

I think the last few posts have summarised the Mull of Kintyre case very well! ... but the President of that BoI hasn't done too badly ........ ;)

[GOLF_BRAVO_ZULU]

For Info;

Work culture of Red Arrows to be probed at pilot's inquest - Telegraph (http://www.telegraph.co.uk/news/uknews/defence/10469117/Work-culture-of-Red-Arrows-to-be-probed-at-pilots-inquest.html)

7:32PM GMT 22 Nov 2013


The culture of the RAF's Red Arrows is be investigated at an inquest into the death of a pilot who was killed when he was ejected from his cockpit following claims that overwork may have played a part in his death.

A pre-inquest hearing in Lincoln was told pilots and ground crew working for the crack aerobatic team will be among over 40 witnesses called at the hearing into the death of Flt Lt Sean Cunningham, due to be heard in January.

The hearing this week was told issues with the ejection seat trigger and the working of the parachute will also be examined by the Central Lincolnshire Coroner Stuart Fisher. Mr Fisher said: “What initiated the ejection seat and why didn't the parachute open are primary matters I am going to be looking at. “I am also going to be looking at cultural issues as well. We are going to have a lot of evidence about culture.”

[Chugalug2]

BGG:_
Train will be along any moment, I hear chugging already.
Sorry I'm late. Staff shortages at Clapham Junction!

I would agree with other posters, that too little has been revealed about this tragedy for much meaningful comment yet. As regards the wider matter of RAF BoIs suffering interference from stellar heights, many thanks to those who reveal that they suffered this and resisted. There again those who did, but then didn't, are unlikely to be so forthcoming.

Even so, the job of a BoI is to discover the most likely cause(s) of an accident and recommend how they should be avoided in future.

In that regard the infamous Mull BoI might well have not done the AOC's bidding, but by the same token it failed to discover that the entire HC2 fleet had been Released to Service in a Grossly Unairworthy state. That despite a witness to the fact wishing to give evidence accordingly, but then ordered by his Station Commander to keep quiet unless and until he was called for. He wasn't.

So resisting undue influence just isn't enough. It needs the Investigating Board (the MAAIB) to be entirely independent of the Operator (aka the MOD/RAF/RN/Army), and of the Regulator (the MAA, aka the MOD). We have a long way to go before Military Air Accident Investigation can not only be effective but seen to be effective.

[Mogwi]

Sadly this was not only a problem with RAF BOIs. I was on the RN board into a (crab exchange) practice bomb that achieved a DH on one of HM's carriers some 20 years ago. It became obvious that there was a glitch with the "LOFT" software. On being informed of this, the MOD stated that it was NOT a software snag as this was the FA2 software and couldn't be changed and that "if it's the Crab's fault - then that's OK."

Luckily, we were able to prove without doubt that it WAS a software snag and not a swx pigs. I retired shortly afterwards and later had the immense pleasure to have said Crab exchange pilot as my F/O on a trans Atlantic aluminium overcast. To give the RN their due, no one tried to modify the board's findings.

[NutLoose]

The CAA have just issued an Emergency AD to check the drogue chute shackles on all MB seats

http://www.caa.co.uk/docs/33/20131126MPD2013005E.pdf

[Just This Once...]

Are all the potential prosecutions, serious service offences and service discipline investigations all off the table or do we still have a bunch of people with the Sword of Damocles hanging over them?

[langleybaston]

It happened down at at TACEVAL level too.

I was at least twice told "you cannot possibly say that about a fellow NATO Met Office"

Even if it is true.

Answer:

"Bollocks. That is my report. Do with it what you will!"

[Courtney Mil]

No, the EAD in itself is nothing other than a timely and correct directive to inspect those components. It offers no opinion about cause or possible blame. It has been accepted by MB because they hace an excellent reputation and have saved hundreds of lives. Your speculation is ill-placed. If the investigators found a possible factor (not stated here) or simply an issue that needs investigation they are following sound procedures to follow up and ensure that there isn't a fleet-wide issue - it doesn't mean it was a cause in this tragic incident. A sensible precaution that has, as far as we know, no stated causal relevence to this case. You need to wait for official findings before drawing conclusions.

[Canadian Break]

That would be Benny the Spider then?

[Bubblewindow]

Slightly off topic but just to give my few pence worth re: inquiry's.
Having recently retired after 20+ years service ive many grievances to air but will leave that for another time (probably when hammered at christmas!).
But I would like to say this about inquiries and investigations.

With thousands of hours under my belt as aircrew I made a very minor error on a flight one day (all errors are bad of course) that was actually caused by the guy up front by virtue of the fact that the flight regime changed un-announced to me (by the PIC) while I was performing a task that required straight and level flight. Sounds complicated but i dont want to be too specific.
A report was put in and I was requested to join the chief flight safety officer for a meeting (a bollocking but thats not allowed in these days of CRM of course).
Previous to the meeting I was asked to submit my own account of events.
What the FS Officer wasnt expecting was a full eight page report from me accounting for every minute from brief to de-brief. It became quite apparent that the whole mission was a classical 'Swiss Cheese' model from start to finish with my very minor error being used a scapegoat by the PIC to vent his anger at his own mistakes and embarrasment at what was a failed mission (luckily simulated).
What happened next shook me to the core after completing recurrent CRM courses year after year. I was advised (told) to withdraw my report as it showed the others involved in bad light and they will more than likely find a way to 'pay me back' at a later date!
So to get to my point, CRM b€&@ox, its just a box ticking excercise. The sh1t still rolls downhill. Im just glad to say ive retired with all limbs attached and i hope my mates will be the same.
Sorry if this is too off topic,
Still venting years of gripes,
Cheers,
BW

[RetiredBA/BY]

I am somewat surprised that the CAA is issuing a directive about military equipment.

Can anyone enlighten me as to why that is?

My guess is that a small number of seats are in cilvilian use but not Mk 10s
surely.

(Ejectee 440)

[Chugalug2]

Bubblewindow:-
I was advised (told) to withdraw my report as it showed the others involved in bad light
... and that just about sums up the problem with RAF Flight Safety, where reputations are of more concern than accidents, for fatal air accidents from minor occurrences do grow. There is the raison d'etre for the Mull Finding; pin it on the two dead pilots otherwise we're all in the s**t. In your one bitter experience can be found the real need for a separate and independent MAA and MAAIB, both from the MOD and from each other.
Thank you for your testimony.

[LOMCEVAK]

Mk 2, 3 and 4 seats as used in Hunters, Jet Provosts etc also have a scissor shackle the same as the Mk 10 seat on the Hawk.

[Heathrow Harry]

I also thought the CAA covered Civil only (as it says on the tin) and that the MAA covered the RAF

"Part of the Ministry of Defence (MOD), the MAA is an independent and autonomous organization responsible for the regulation, surveillance, inspection and assurance of the Defence Air operating and technical domains. It ensures the safe design and use of military air systems. As the single regulatory authority responsible for regulating all aspects of Air Safety across Defence, the MAA has full oversight of all Defence aviation activity. Through independent audit and continuous surveillance of military aviation, the MAA aims to provide the Secretary of State for Defence (SofS), through the Permanent Under Secretary of State for Defence (PUS), the necessary assurance that appropriate standards of Air Safety are maintained in delivering operational capability."

but the CAA notice includes:-

"In accordance with 22(1) of Air Navigation Order 2009 as amended the following action required by this Mandatory Permit Directive (MPD) is mandatory for applicable aircraft registered in the United Kingdom operating on a UK CAA Permit to Fly"

Looks like the CAA are muscling in..............

[tucumseh]

the MAA aims to provide

Perhaps CAA intervention is a necessary evil until the MAA's aim is achieved.

[Heathrow Harry]

No-one with any sense would "promise"

Have to use the weasel words like "aim" to protect yourself from the Press and any future investigation

[NutLoose]

but the CAA notice includes:-

"In accordance with 22(1) of Air Navigation Order 2009 as amended the following action required by this Mandatory Permit Directive (MPD) is mandatory for applicable aircraft registered in the United Kingdom operating on a UK CAA Permit to Fly"

Looks like the CAA are muscling in..............

They do just cover Civi, but ex Military are on a permit such as Hunters, Gnats and Jet Provosts, hence the Emergency AD to cover those, but as it does not state seat models, simply all seats it does make you wonder if this will be a two way thing, and something will have happened for them to issue it in the first place.

[tucumseh]

HH

Well, the Secretary of State requires them to do it, so one wonders why they are permitted to only "aim". Perhaps it is applied realism, given they are part of the MoD and at the mercy of masters who can, and do, tell them what to do and where to go. Now, if they were independent.......

[Bob Viking]

I've had a crap nights sleep so maybe I'm being overly grumpy but here's my thoughts this morning. This thread is about the report into the death of a young guy many of us knew. There has been no hint of any witch hunt or wrongdoing during the process. Therefore, would it be at all possible for people to take their whinging and stories of crooked flight safety empires somewhere else please?
Feel free to ignore me but it's just my two penn'th.
BV

[lj101]

Chugalug with reference to Bubbles;

I was advised (told) to withdraw my report as it showed the others involved in bad light


... and that just about sums up the problem with RAF Flight Safety, where reputations are of more concern than accidents, for fatal air accidents from minor occurrences do grow. There is the raison d'etre for the Mull Finding; pin it on the two dead pilots otherwise we're all in the s**t. In your one bitter experience can be found the real need for a separate and independent MAA and MAAIB, both from the MOD and from each other.
Thank you for your testimony.


Apart from the fact that Bubble has never been in the RAF or indeed the British Military (according to himself on a previous thread).

[Wander00]

IMHO, BV has suggested the appropriate line - I too agree (although I did not know the guy concerned, a long time ago I had close involvement with RAFAT as a RA Trustee) that this is not the place for going on about MAAB, MAA, etc - there is another thread is/has been running for that.

RIP Sean Cunningham

[ASRAAM]

The latest MPD is applicable to Martin Baker ejection seat equipped aircraft operating on the civilian register. I'm fairly sure that all mb seats share a similar scissor shackle mechanism so the potential problem is common to all.

It replaces an earlier MPD that was issued shortly after the Red Arrows hawk accident. Most of us surmised at the time that a fault such as this could have been the cause of the main chute failure to deploy. (although not why it fired in the first place).

The new MPD requires operators to comply with a procedure outlined in Martin Baker Information Leaflet 704a. I have not yet had sight of it so I don't know how it varies from the original one issued after the accident

I am sure that military operators will issue their equivalent of an MPD requiring the same compliance with MB Leaflet 704a

[Rigga]

National ADs (and MPDs) are free on the CAA website

Mandatory Permit Directives | Continuing Airworthiness & Maintenance | Operations and Safety (http://www.caa.co.uk/MPDS)
and
CAP 661: Mandatory Permit Directives | Publications | About the CAA (http://www.caa.co.uk/application.aspx?catid=33&pagetype=65&appid=11&mode=detail&id=215)

[NutLoose]

BV
I personally wasn't being judgmental nor subjective and hopefully not disrespectful, I was simply trying to be informative in letting people know that the CAA are being proactive with regards to Ejector Seats.

[Bob Viking]

You can rest assured that your posts did not make me grumpy.
The classic Pprune tangents are fine on most threads but on a thread disussing something like this I would just rather they were kept a little more relevant.
Just my opinion of course. Others may differ.
BV

[GOLF_BRAVO_ZULU]

When I re-energised this Thread, on the strength of the Telegraph news item, one of my selected quotes from the Coroner was “I am also going to be looking at cultural issues as well. We are going to have a lot of evidence about culture.” I thought that statement would initiate some debate. I was wrong, though, as it didn't.

Maybe I'm uniquely paranoid about the implications of influential professional civilians delving into military life. I think that goes a bit wider than airworthiness and BoI policy/habits/traditions.

[dervish]

“I am also going to be looking at cultural issues as well. We are going to have a lot of evidence about culture.”

As the MAA are I think charged with correcting "cultural issues" I thought the references to them and BoI failings entirely appropriate. Bubblewindow's post was particularly revealing but obviously not what is required in today's MoD. Can't have people revealing the failings of senior officers old chap.

[Wander00]

The potential problem with "civilian" enquiries into "Service" matters, is precisely the issue - "cultural" - perhaps in sad circumstances such as this, a Coroner might consider appointing a "service" assessor or advisor

[ASRAAM]

Rigga,

MPDs are indeed free to access. In fact the CAA are kind enough to email them to me.

Unfortunately this one provides no engineering detail at all other then requiring compliance with Martin Baker Special information Leaflet No 704a.

Now if you happen to have a link to that leaflet it would be most helpful.

[Chugalug2]

lj101:-
Apart from the fact that Bubble has never been in the RAF or indeed the British Military (according to himself on a previous thread).
Thanks for that, which no doubt BW will wish to confirm. The obvious lesson for me to learn is "Don't assume, check"!

In mitigation I would proffer the nature of his post (rear seat non pilot aircrew incident) on a Military thread about a very Military accident, though on the other hand he did preface it by saying that it was slightly off topic. So apologies for getting him wrong and using him as a stick with which to beat RAF Flight Safety with. Anyone wish to offer another instead? :)

As to this thread not being an appropriate one for comment about the limitations of Military Air Accident Investigation, it joins many others that were also the tragic subjects of Fatal Military Air Accidents. The Naval Baggers mid-air, the Blue on Blue loss of a Tornado, the bringing down of a Hercules fitted with unprotected Fuel Tanks, the loss of a Nimrod fitted with an unairworthy Fuel System, and of course the Mull Chinook.

62 lives lost, yet each of those 5 threads declared an inappropriate place to air the idea that they were all related, because they were investigated by the operator that suffered the accident. In many of those accidents NoK were lied to, and were most energetic subsequently in their search for the truth. That should have been the point of the various BoI's in the first place, shouldn't it? Or doesn't it quite work like that?

[tucumseh]

I think one of the cultural problems is paranoid secrecy, usually to protect senior staffs.

I recently asked for a document relating to a fatal crash. Given the Coroner agreed, and is on record, there had been a Pre-Inquest Hearing (PIH) to determine who would be witnesses and what would be discussed, I asked why a certain report had been withheld (having established it wasn’t even submitted to the Coroner).



MoD replied that there had NOT been a PIH and the subject report (and the investigation that produced the report) did not exist/had not taken place. I replied, quoting the report and naming the four immediate recipients plus the Investigating Officer, only for MoD to deny its existence again. They repeated this to families, who also have the report; which merely alienates and reinvigorates them.



Lacking this report, the Inquest immediately went off at a tangent (a direction determined by MoD, with no family input) and little of substance or relevance was discussed in 4 days. Thus, the Court was grossly misled and the underlying failures that led to the BoI’s contributory factors remain uncorrected, with the MAA studiously ignoring them. Probably because the above report demonstrates, beyond any doubt, that all contributory factors were identified up to 8 years in advance, and staffs instructed not to correct them, to save money. So, the Coroner DID have “Service” advisors, but they toed the MoD party line and colluded in misleading him (because none told the "whole truth"). This is common practice. I’d prefer Coroners to have independent advisors; perhaps reputable retired staffs with proven experience. So, no MAA, on both counts!

[Rigga]

ASRAAM,
My access to Martin Baker is only for Crashworthy seats not ejectors - sorry.

CULTURE:

The reason why this apparently officious Coroner is allowed to look at RAFAT Culture is because - unlike the rest of the RAF - they regularly fly and do quite dangerous stuff directly over the public's heads.

Don't forget, it is the CAA who allow RAFAT to fly at Air Shows - not the RAF or MAA or even MOD. If the Coroner provides enough evidence of the "wrong stuff" to the CAA the RAFAT will be banned from UK shows. Simple.

[orca]

I think that if any unit had a mid air and two fatalities in quick succession their culture would be placed under a degree of scrutiny.

[Dengue_Dude]

All will be apparent in January, along with what's been done about it.

An immense amount of work has been going on by many different agencies. Suffice to say this incident in particular, has been treated with the utmost seriousness and urgency.

[pr00ne]

Rigga,


"The reason why this apparently officious Coroner is allowed to look at RAFAT Culture is because... -"

...is because he's a coroner, he doesn't need any other reason, the fact that it involves the military is neither here nor there.

[Rigga]

Proone - You are, of course, wrong.

For a Coroner to require access he needs to be on duty - and the inquest is his reason.

[longer ron]

Things have changed over the years !
Because there was a fatality in this case - the Aircraft/Evidence etc was under the control of the civvy cops and the investigation team and BOI members would have had to work with the civvy cops and ask for access etc.
With a fatality - it is no longer a purely military matter !

[just another jocky]

l ron...it doesn't require there to be a fatality for the police to have primacy.

[lj101]

House of Commons - Armed Forces - First Report (http://www.publications.parliament.uk/pa/cm200506/cmselect/cmarmed/828/82806.htm)


INVESTIGATIONS IN THE UNITED KINGDOM

63. We have acknowledged the difficulties faced by the Service police in investigating incidents in operational theatres. There has also been criticism of investigations in the United Kingdom. The Defence Committee's 2005 Duty of Care report noted: "A consistent criticism from the families of recruits who died during their initial training is that the deaths of their children were not properly investigated".[108] The investigation of unexplained deaths of this sort are subject to a protocol between the Service police forces and the Association of Chief Police Officers that sets out the circumstances in which the civilian or Service police forces take the lead in an investigation.[109] In written evidence, JUSTICE expresses concern about "how issues of jurisdiction will be resolved when both civil and Service authorities have jurisdiction in any given case".[110] Within the United Kingdom the civilian police, and therefore the civilian jurisdiction, has primacy for investigations. As Brigadier Findlay explained, "There is absolutely no doubt in the minds of the Service police over the complete primacy of the civil authority to investigate all issues within the United Kingdom".[111] Mr Rooks described the normal arrangements with the civilian police, saying that:

The Home Department civil police have primacy on everything, but there is a protocol which is formalised with the Home Office which sets out what will happen in normal circumstances and […] that a list of serious crimes, which include murder and rape, will automatically be reported by the Commanding Officer or the Service police, if they are the first responder […] to the Home Department police force and they then decide how to deal with the investigation. For a serious crime of that sort they will almost certainly decide to lead that investigation themselves. They may well use the expertise of either the Service police or the MDP, but they will definitely be in the lead.[112]

[NigelOnDraft]

MPDs are indeed free to access. In fact the CAA are kind enough to email them to me.

Unfortunately this one provides no engineering detail at all other then requiring compliance with Martin Baker Special information Leaflet No 704a.

Now if you happen to have a link to that leaflet it would be most helpfulThe first MPD (shortly after the accident) was, as stated earlier, to ensure the scissor shackle had a degree of freedom of movement.

As hinted in the MPD, the new MPD is not much different, but adds a technical measurement e.g. a defined minimum gap, between certain components.

Clearly the MPD(s) may be entirely coincidental to the tragic events under discussion, but I somewhat suspect not :oh:

Heathrow Harry:but the CAA notice includes:-

"In accordance with 22(1) of Air Navigation Order 2009 as amended the following action required by this Mandatory Permit Directive (MPD) is mandatory for applicable aircraft registered in the United Kingdom operating on a UK CAA Permit to Fly"

Looks like the CAA are muscling in..............I do not see the CAA muscling in at all. PtoF aircraft are regulated by the CAA, and if MB have seen fit to issue leaflets affecting Flight Safety, then the CAA certainly should pass on that info to the appropriate operators ASAP. As a MPD does.

NoD

[lj101]

http://www.maa.mod.uk/linkedfiles/regulation/jap01/chapter1.pdf

Air Navigation Order
Air navigation in the UK is regulated by the Air Navigation Order (ANO), which is a statutory instrument made pursuant to the Civil Aviation Act (1982). However, the majority of the provisions of the ANO do not apply to Military Aircraft, with the notable exception of the Rules of the Air.

The MOD direct the military (via JSP550) to comply with the Rules of the Air as prescribed in the ANO except where operational/training needs dictate. In other words, military aviators are required to comply with the Rules of the Air unless a flight is specifically authorised not to comply (low flying being the best example).

Not sure of the relevance of the above but I found it interesting enough to quote.

[Bubblewindow]

I must appologise if I upset anybody whining about my flight safety issues and yes Im not Ex-RAF nor British Forces. Its good to talk though.

Cheers and safe flying,

BW

[dervish]

Hey bubble, no problem. Keep it up I say. :ok: You only have to look at the Wg Cdr Spry stickie thread to see very few in MoD are interested or able to answer valid questions.

[Chugalug2]

dervish:- "You only have to look at the Wg Cdr Spry stickie thread to see very few in MoD are interested or able to answer valid questions."


Indeed. It is as though some think that they can learn a foreign language by merely studying a dictionary in that language. When they find that they can't they then change the meanings of the new words they have learnt to suit their purposes. In other words, pure gobbledygook. It would be amusing and entertaining, as Air Clues clearly tries hard to be, if it were not for the deadly seriousness of mangling the process of Air Safety thus.


Bubblewindow, worry not for it was not you at fault but I. At least you are interested in promoting Flight Safety, a rare trait hereabouts.

[Rigga]

Chug,
If this was Facebook I'd "Like" that comment and write LOL after it.

[Chugalug2]

Thank you Rigga, but let us be thankful that PPRuNe has no such facility, for I suspect that I would be in serious deficit of such 'Likes' I'm afraid. That perhaps is the whole point.
This isn't a popularity contest nor even a game. It is about the ultimate goal of Air Safety, ie the saving of lives and equipment so that they are available for their true purpose and not wasted in avoidable accidents. Which brings us neatly back to the thread OP...

[thefodfather]

I have met many people seeking to publicise Flight Safety on this forum and urge them them to work hard hard in their endeavours. The situation has changed beyond belief in the past 10 years and I hope that others are buoyed by this improvement stead of being dissuaded by the negative,

[Rigga]

Chug,
I don't speak the same language as you clever guys, I don’t read Grown-Up newspapers and I don’t drink G&T’s. I only have vocational qualifications (none of those degree things) and some 38 years of experience.

But I do understand what goes on around me and I am where I am by putting the intent (not the letter) of regulations into practice. Some may call that 'doing the right thing'. I have some strong influence in some air & ground ops, maintenance, design and production organisations.

Whilst working in a relatively senior position for a large contractor I saw how bad the latter day RAF had become and decided to wait for H-C to come up with some sort of alternative path in his recommendations. If he had said he was happy with the RAF way of doing airplane stuff - I'd have resigned immediately and then looked for new work.

However good or bad you see his report, the way H-C described the way forward was (to me) a logical step on the path to MOD's redemption and I supported it (and I still do, however wrong the details of the report are/were).

Since then I've seen the MAA try to mould new regulations around their old practices and I've also seen how it can't and doesn't work. I saw what they wrote and heard what they told their Shop floor - and then I saw what they really wanted to happen and how they can't operate without (their term) 'work-arounds'.

I gave up after a few years of driving myself mad with frustration. Even now, some regulations are ignored if not recently removed because they meant actually changing a 'traditional' policy.

In my opinion the MAA is now changing the rules to revert back to where they were pre-H-C. I believe the MAA will soon become just another Dept. of MOD, more worried about its budget than doing anything right, effective or productive.

I now work with people who live for and with airworthiness and continued airworthiness, and not doing their utmost to get around 'difficult' regulations (ironically, it's my job to see what Directors want to work around - and I almost always reject it). I work where doing the right thing is normal, the easiest path and is cost effective - because that's the way it is and we budget/work to that cost.

Oh!....and you couldn't have this standard of conversation on Facebook. That’s one reason I’m on here.

Fodfather,
To which improvement are you referring? What part of MOD aviation are you working in to see that improvement?

[tucumseh]

Rigga, what an excellent post.

In my opinion the MAA is now changing the rules to revert back to where they were pre-H-C. I believe the MAA will soon become just another Dept. of MOD, more worried about its budget than doing anything right, effective or productive.

My own experience, while from a slightly different viewpoint, is exactly the same. MoD no longer waltzes round this issue in replies to Ministers. They quite openly confirm the old “pre-Haddon-Cave” practices (not regulations) remain acceptable. That is, inter alia, correct implementation is optional and instructions to render aircraft unsafe must be obeyed. The DE&S secretariat responsible for drafting and issuing these replies routinely quotes and upholds past rulings by 2 and 4 Stars to this effect; and, in fact, did so as recently as last week when citing a 1999 ruling by Sir Robert Walmsley, Chief of Defence Procurement. (I like to think this is where Haddon-Cave was aiming when he made his scathing remark about submariners managing airworthiness). Walmsley, lest it be forgotten, was rabidly anti-engineer, anti-airworthiness. I accept he had other distractions during his tenure (!), so equal blame lies with his 2 Stars and Director of Personnel, Resources and Development, who egged him on in his rulings. All were sufficiently stupid, or arrogant, to place these in writing. DE&S confirms the MAA support these historical rulings. The MAA were formally notified of them by two Ministers, but did nothing.


I think one point is always worth repeating. It was not the regulations that were lacking, but the implementation.



Finally, the MAA are and always have been just another MOD department. They have made no attempt to do the right thing, choosing to ignore the root cause of the problem.

[Dengue_Dude]

Rigga - Respect.

[Chugalug2]

Rigga, I can do little more than echo tuc's comments. Your post was from the heart and all the more worthy for that. If all who posted re Airworthiness and Air or Flight Safety did likewise this dialogue would be all the more valuable and effective.
I know that we disagree about the Haddon Cave Report and suspect that will not change. So be it. My problem with him is that he was given clear evidence of the deliberate destruction of the UK Military Airworthiness system and chose not only to ignore it but to characterise that time as a 'Golden Period'. That really had the imprimatur of the MOD 'advisors' that 'assisted' him in the preparation of his Report. Thus were the perpetrators of the destruction protected, thus was the solution to their subversion prevented. Despite the urgent need for a separate MAA and MAAIB (both of the MOD and of each other), by protecting those VSO's he obscured that need and recommended instead inclusion within the MOD fold. Hence history can now be repeated ad infinitum.
That is my problem with Haddon Cave, that it is his Report that is responsible for the clay man that is the MAA, and for that matter the MAAIB. So no tff, I cannot share your enthusiasm for them and what they are, but rather urge others to demand that they become what they should be, what any Air Regulator and Air Accident Investigator should be, independent of the Operator and of each other.

[Rigga]

Gents,
Our differences on the why's and wherefore's don't detract from our unity in getting some justice done and getting some independence where it's needed.
It's all Grist to the same Millwheel.

[thefodfather]

The debate is always interesting and while there are still many things that still need to be improved and made to work better in the world of military aviation safety, I stand by the comment that a lot has changed for the better. Most of that is cultural and hard to quantify. However, by way of example, I remember organising a safety related conference in 2003 where as an SO3, I was the highest rank in the room. I couldn't even find an SO2 to do the welcome speech. A similar event 8 years later saw 2 Gp Capts fighting over the opening speech. When I first started working in safety it certainly wasn't seen by my peers as a good career move. Now 12 years later a job in safety is becoming more of a prerequisite for promotion.

A real example of improvement is to compare the old signal Flight Safety report process with what we have with ASIMS. Whilst there are some issues that the MAA might not have dealt with from the past, to suggest that they have made no attempt to do the right thing is very unfair indeed.

[obnoxio f*ckwit]

When I first started working in safety it certainly wasn't seen by my peers as a good career move. Now 12 years later a job in safety is becoming more of a prerequisite for promotion.

Which means that instead of being staffed by those who were actually interested in safety and/or had no career to worry about and therefore were perhaps inclined to do the right thing, it is now staffed by thrusters who view rocking the boat or making the wrong noises as potential career stoppers, and thus are more likely to toe the party line and make no decision in case it turns out to be a wrong one. And consequently little actually changes.

Or is that a bit harsh?

[Rigga]

Fodfather,
I stand corrected at your experience and I might agree that what you say shows a significant improvement in attendance.
However, my experience is that every one of the heavily publicised policies and processes made in high offices, conferences, seminars and the like, are only tested on the shop floor. Only the practises there can make a significant difference to any 'safety culture'.
Rules are only effective if people read them and act on them.

[Chugalug2]

Rigga, words of wisdom in both your last posts, especially:-


Rules are only effective if people read them and act on them


That is where things went wrong and still do. The Regulations need to be regained and enforced. The MAA doesn't do that, instead it rewrites them to suit the MOD's agenda. It will go on doing so until it is free of the MOD yoke.


Your conferences may have been acclaimed successes tff, but that is not the point of Air Safety, which is to avoid avoidable accidents. You can only do that with slow evolution. Instead of that we have seen a pogrom waged against those who were trained and experienced in applying the Regulations, so that both they and the Regulations are but distant memories.


The MAA was founded on this morass, in a state of perpetual revolutionary fervour. It won't work, unless it can be made truly independent and sets about rebuilding outwith the MOD what has been lost within it. Just as importantly all that goes for the MAAIB also. Rather than starting from a Year Zero, both have to reach back to the roots of best practise before the suborning started.

[dragartist]

Fodfather, I may have attended your Fod conference at Metropole in 99. Recall the marble room. I spent some time as a Safety Manager. At the time we were quite proud of the systems we were introducing to manage hazards (we called them risks at the time!) I think the Engine crowd were ahead of the rest.


Frankly I found the job boring. I was not looking for promotion. I think some of the EAs welcomed my contribution and help. At least a couple are still in contact 14 years later.


I could not wait to get back into a proper job where I made decisions and made things happen. I consider that I embraced safety without the need for the watershed moment and subsequent initiatives. what I saw and did not like was how the resources were thrown at Safety post HC. it became an industry with each IPT having a complete section. What they actually did and the contribution they made to real safety in my experience is questionable. I saw QQ milk the situation to the extreme aided an abetted by the Safety Management Section. I don't think they managed Safety just managed a contract with QQ or others.


I am not suggesting for one minute that the resources were not needed. What I think we all needed was fewer projects such that those with the responsibility could do the job thoroughly which means drawing up the safety argument not delegating it to others. What actually happened was we took our eye off the ball looking to do things cheaper. More for less, RAB became more important than Airworthiness in spite of what the VSOs were saying on every Business Plan and mission statement.


I did learn some lessons from my time in Safety Management. the biggest thing was to get to know how the kit worked and how it could kill those who operated it. without that understanding you fail. I think it may be called Engineering. Those employed in Safety Management posts should be deployed to the real work where they can make a difference.


I think you were spot on Rigga.

[Courtney Mil]

Rigga, wise words as always.

obnoxio f*ckwit, you make a very good point. I guess the same could be said for any post regarded as a stepping stone.

[tucumseh]

to suggest that they have made no attempt to do the right thing is very unfair indeed


What has the MAA done to address the root problem that led to the Nimrod Review, which in turn led to their formation?

Nothing. They deny it even happened.

That being so, everything they do lacks a solid foundation and direction. They may get a few things right, but for entirely the wrong reason.