Flt. Lt. Sean Cunningham inquest [Archive]

Jobza Guddun

11th Jan 2014, 13:53

"Is this staffing level shortage indicative of the RAF squadron strength as a whole?"

Nutty,

In my (not inconsiderable) recent experience numbers of troops is certainly an issue, especially due to 'diversions'. However, more painful is the comparatively lower levels of experience available on the trade desks than years gone by, touched on by Sqn Ldr Higgins.

This has been caused by a number of factors - redundancies, PVR, and a misguided manning policy of moving people around after 5 years. Fine when you have larger numbers of personnel, you can absorb it, but when you are down to the bare bones anyway, each experienced guy leaving hurts a lot more. Replacements from another type takes so much time to bring on, as there's no capacity for full-on mentoring of the new guys, not the way I was inducted that's for sure.

What Sqn Ldr Higgins describes has been the norm on the FJ sqns I've known in recent years, with the pressure to keep the pilots even minimally current tangible. Every so often we see that the Reds flew more displays than ever, yet they're doing it with a smaller workforce?

Sean must have been terrified for those last seconds when he realised he'd not separated. I hope this inquest does him full justice, doesn't just end up with someone on the Reds being a sacrificial lamb, and leads to a Service culture that acknowledges the present limits of manpower and equipment and plans accordingly.

Genstabler

11th Jan 2014, 13:57

More likely just a clear fact presented to the coroner.
...and seized on by the media as a means of inflating the story. I doubt that self medication was a significant factor and fail to see how it could be used as a cover up for anything. Too many conspiracy theories.

Two's in

11th Jan 2014, 14:11

how does any amount of cough medicine, or whatever else, affect the opening of the 'chute????

It doesn't. But it does help the inquiry or inquest build a complete picture of the individual and the organisation. Same with the mobile phone. If there are instances where rules and procedures are not being adhered to it highlights a number of factors;

1. If those rules are pointless, why are they not being challenged and removed?
2. If they are valid, why are they being ignored?
3. How does the command structure view such rules and the somewhat arbitrary nature of compliance?

It's all well and good lining up the holes in the cheese to point out the MoD are crass, negligent, malfeasant and all the other things we know them to be, but that's a two-way street. The unit and the individuals will also come under that spotlight and any examples of non-standard or non-compliant behaviour will be subject to scrutiny, already under the BoI.

As an authorising officer I would ask crews to imagine how any of their actions would look to a subsequent Board of Inquiry before they did them. This is exactly what is happening here, albeit at the inquest. Minor infringements of rules, or the ignoring of rules by those entrusted to apply them, can sometimes be signs of stress, overstretch or command issues, thus they form part of the overall indication of the health of the unit.

NutLoose

11th Jan 2014, 14:14

I think you will find, it all has relevance, the seat may not have functioned as prescribed, but that is not the whole story, one accident is often a culmination of several sets of circumstances.

A pilot possibly operating under the weather and errors happening within the cockpit resulting in the seat firing.

An inexperienced engineering team, grossly undermanned, operating to tight schedules and being rushed to generate aircraft without sufficient time to do the task correctly with inadequate manuals and without breaks

A management team aware of all of these failings within the team, but failing to address them or putting a stop or a reduction in the programme until they are addressed.

A senior management team in the RAF ignoring the serious undermanning issues and pressures being exerted on the team to comply with the planned programmes.

A Government cutting back on Service personnel and overburdening them with tasks without regard to safety and operational capability, and those senior officers playing lip service to the problem without standing up for those they are supposed to lead.

Everyone of those issues lead to and compounded to make this accident happen, without learning from, understanding and addressing all of those problems, one would simply be playing lip service to an inquiry and not learning from it.
And without the inquiry and the facts being laid out for all to see and learn from, you are in effect setting a whole series of actions off again that will lead to more deaths in the future.

dctyke

11th Jan 2014, 14:30

Here's a fact for you. In the 80's that shackle would have been tested/inspected in the ejection seat bay every 6 months. It then changed to every 12 months, then it changed to every 24 months........ no idea what it is now (they were talking 5 yrs when I left the RAF). I also believe all the unit ej seat bays are now shut down and seats are now crated up and serviced in one location. When I worked in ej seat bays (3 tours) it was not unusual to be called out to sqns for a 2nd oppinion on things the sqn armourers were not happy with, this is not possible now.

Glad I'm not working under the engineering conditions the lads have to suffer now.............

mad_jock

11th Jan 2014, 14:46

When I worked in ej seat bays (3 tours) it was not unusual to be called out to sqns for a 2nd oppinion on things the sqn armourers were not happy with, this is not possible now.

And how often did this result in a not fit for use seat being "grounded" instead of being flown?

NutLoose

11th Jan 2014, 14:49

As an Engine trade posted onto Jags at Bruggen I had to do a three day course at the Bruggen armoury on the seat, I wonder if the still do the same.

just another jocky

11th Jan 2014, 15:03

Until the cause of:

a) the initiation of the ejection and...

b) the failure of the main parachute to deploy....

...are known, speculation as to whether a mild overnight medication had any effect is inappropriate in my opinion. It may become relevant, but right now, it's not.

I have never, in 31+ years flying in the RAF, seen a ban on mobile phones in the cockpit. They should either be in Flight Mode or turned off, but the mere presence of a mobile phone, turned off, in the cockpit, is irrelevant. Perhaps the army were finding their crews were actually using them on the flight line. :eek:

Clearly they didn't have the special mobile phones that surgeons, movers & the AARC have. :rolleyes:

The Old Fat One

11th Jan 2014, 15:43

I hope this inquest does him full justice, doesn't just end up with someone on the Reds being a sacrificial lamb, and leads to a Service culture that acknowledges the present limits of manpower and equipment and plans accordingly.

Could have picked a number of quotes on this thread to highlight this point, which seems so widely misunderstood...

It is not the job of an inquest to apportion guilt or blame or indeed to be seen to do so. It is the job of an inquest to establish the cause of death, or to record an open verdict and that is all. Ergo an inquest cannot dispense justice of any kind.

That's a good post by Two's In btw.

I'd lay odds on the medicine angle is a cover up!

Utter nonsense. The coroner would have ordered an autopsy. The person doing it would present results. To do otherwise, would be to break the law.

Cows getting bigger

11th Jan 2014, 16:03

One of the 'advantages' of inquests and inquiries is that a number of lessons can be learnt. Sure, there is often a very small number of causal factors but if other things can be identified..........

I'm not an FJ expert but the little nuggets that I would be looking at, irrespective of their (non) contribution to this sad accident, would include mobile phones (try using your mobile on the apron at many civil airports :eek: ), procedures for helmet visors/oxygen masks and self-medication. None of the above should be considered as criticism, it is just best practice in an industry where we should always be looking to manage risk rather than just ignoring it.

dctyke

11th Jan 2014, 16:43

Mad Jock: And how often did this result in a not fit for use seat being "grounded" instead of being flown?

I have never known in my 36yrs, a 'not fit for use' seat being flown, who could (or would) auth that?

mad_jock

11th Jan 2014, 16:56

Sorry that's not what I was meaning I am a civi BTW who served in the army none aviation.

What I meant was if it was common that when you got called over as the expert on the seats you discovered a problem which might have slipped through if they hadn't had the onsite "expert" readily available.

NutLoose

11th Jan 2014, 17:51

A Servicing Bay staff member would tend to have a greater in depth knowledge of the seat and It's foibles, hence calling them in to give you a second opinion, you would tend to defer to that knowledge and go with their recommendation.
At the end of the day, if everything else goes t*ts up! it is that one item that is going to save a life.

It wasn't common to call them in, but it did happen occasionally to verify your feelings and offer advice to make a sound judgement.

Added, but that was when I was serving when each Station tended to have bays on Station.

helen-damnation

11th Jan 2014, 21:05

Seadrills
Secondly, I understand from a friend in the AAC that mobile telephones are not allowed in the cockpit and should be left at the line. But it seems as though every aviator I talk to always, always flies with their mobile phones with them.

Any significance to those 2 points ?

Not if it's turned off and hence, not transmitting.

Easy Street

11th Jan 2014, 22:22

In case any of the self-professed non-experts were getting too deeply into the significance of in-cockpit mobile phones to this accident, I thought I'd point out that the ejection sequence of the Mk 10 seat involves no electric or electronic components. The system is operated entirely by gas pressure from percussion-initiated pyrotechnic cartridges (and the command ejection system in the Hawk is also gas-operated). This makes the system immune to electromagnetic interference and thus there is no way that stray mobile phone transmissions could have played a direct part in the accident chain.

Dominator2

12th Jan 2014, 10:19

Easy,

I believe that the relevance of the carrying of mobilephones is that of distraction. In my later flying career, when flying a crewaircraft I witnessed a few times crew members being distracted by incoming messages.Of course aircrew should be allowed to carry mobiles, however, the phonesshould remain switched OFF and in a pocket/bag whenever involved in theoperation of an aircraft. The same if true of other entertainment items such asiplayers.

Biggus

12th Jan 2014, 10:34

I used to fly some operational sorties where the mobile phone issued by Ops was the pre-briefed tertiary method of comms.

It was used successfully to that effect on occasions, and somehow I doubt it had any effect on the aircraft's on board, steam driven, valve technology....

And no, it was some "special" type of mobile phone...

Dominator2

12th Jan 2014, 12:17

Biggus

You miss the point. There is a difference between theAuthorised use of a Service Issued mobile device to the random and indiscriminateuse of a private mobile. One of the problems that we faced was educating theyounger generation in what that difference is! Any unauthorised use of a mobiledevice in an aircraft MAY distract someone from their primary task. Somethingas simple as an incoming Message may cause an individual to miss a vital actionor check! If the phone is switched ON it can be the cause of an error beingmade.

Distant Voice

12th Jan 2014, 12:26

Is the Service Inquiry (SI) report in the public domain for this accident?

DV

Bill4a

12th Jan 2014, 12:39

Sorry Nutloose, I can't accept your comment re inadequate servicing manuals, I spent several years at CSDE making sure they were as accurate and fit for purpose as it was possible to be with constant monitoring and revision but unless things have changed dramatically I would hope the standards we set were being maintained. However comma I endorse the rest of your remarks! :}

NutLoose

12th Jan 2014, 12:45

Bill I am quoting what was said at the inquiry, wait a sec and i will post the tweets

Clarkson admits drogue bolt tightening crucial but aircraft manual instructions were 'vague' lincolnshireecho.co.uk/Red-Arrow-Sean…

Engineers pretty much left to their own judgement re drogue bolt tightening lincolnshireecho.co.uk/Red-Arrow-Sean…

Shackle bolt over tightening and affecting the deployment of drogue and main chutes becoming increasingly crucial lincolnshireecho.co.uk/Red-Arrow-Sean…

Clarkson adamant that he was not aware that over tightening of shackle bolts could affect performance of chutes lincolnshireecho.co.uk/Red-Arrow-Sean…

As a side note

As for manuals, the CAA have recently decided to reduce legislation on the smaller side of things, and leave it up to the Owner / Engineer.. Had a long email discussion over this. The attitude now Is anything mandatory in the manufacturers manual, is only mandatory if it is in Section 4 in the CAA's eyes, this in effect wipes out loads of life limits as some aircraft never had their manuals laid out in a standard format. It also in one foul sweep brought a fundamental change in airworthiness, prior to it the book was gospel, now it isn't with parts of it being sanctioned to be ignored, this will in these eyes lead to maintenance by affordability and not by safety whilst encouraging multiple standards, again to the detriment of safety... It's a sad state of affairs, as culpable blame will now point at us for not doing items the CAA deem as not required.. The words arse covering by the CAA comes to mind..

Bill4a

12th Jan 2014, 12:48

Thanks, it probably was but knowing how much effort goes into maintaining schedules in an up to date state it stung a bit!
None of those tweets should be true, there must be a loading set by MB for the shackle bolt, and it would be in the seat schedule or SP. But it will all come out in the wash I'm sure.

Distant Voice

12th Jan 2014, 12:53

Regardless of medication etc, with the firing of a MK10 "zero zero" ejector seat Flt Lt Cunningham should have survived. If the main parachute did not deploy, then perhaps the drogue gun did not fire. Should be mentioned in the SI report.

DV

Biggus

12th Jan 2014, 13:18

D2,

I was merely illustrating that mobile phone usage on military aircraft has occurred, and maybe still does - I was not advocating the use of "personal" mobiles in similar situations, in that instance I fully agree with your comments....

NigelOnDraft

12th Jan 2014, 16:33

DVRegardless of medication etc, with the firing of a MK10 "zero zero" ejector seat Flt Lt Cunningham should have survived. If the main parachute did not deploy, then perhaps the drogue gun did not fire. Should be mentioned in the SI reportAFAIK there is no report e.g. SI, out yet.

However, reading the above posts (inc tweets), and certain related MPDs, it is fairly well known why the main chute did not deploy. And it is not failure of the drogue gun (which again from the inquest tweets it is pretty clear did fire).

NoD

dctyke

12th Jan 2014, 16:54

Must have serviced 200/300 seats in my time but never ever had to touch/adjust/alter the shackle bolt. If I recall correctly the bolt was peined with the nut in position when the seat was manufactured.

edit: Come to think of it I'm convinced that bolt was shouldered and could not be over-tightened.............

airsound

14th Jan 2014, 10:48

Fat OneIt is not the job of an inquest to apportion guilt or blame or indeed to be seen to do so. It is the job of an inquest to establish the cause of death, or to record an open verdict and that is all. Ergo an inquest cannot dispense justice of any kind.Don't disagree, but coroners have been able to make recommendations under something called Rule 43 - for instance in the Hercules and Nimrod inquests.

I would have replied earlier, but there are now some changed arrangements for inquests that were embargoed until this morning by the Min of Justice. Here's some of their news release.Reports made by coroners to help prevent future deaths will be routinely published online for the first time today (Tuesday 14th January).

Following an inquest a coroner may make a report to a person, organisation, local authority or government department or agency with a view to preventing future deaths (a PFD report).

From today the Chief Coroner’s office will publish PFD (preventing future deaths) reports made by coroners on the judiciary website and for the first time the public will have access to these reports online in a readable and searchable format.

HHJ Peter Thornton QC, The Chief Coroner said

“I place great emphasis on the valuable work of coroners in saving lives by highlighting risks which need to be eliminated. That is why publishing these reports and putting them into the public domain is so important.”

Some 600 reports are now made by coroners in England and Wales every year. The topics they cover ranges from reports about speed limits on particular roads to changes in military equipment used in Helmand Province, Afghanistan.airsound

airsound

14th Jan 2014, 10:54

Is the Service Inquiry (SI) report in the public domain for this accident?
As always, DV, good question!

I've been trying to find it, and have failed so far. Phone calls go straight to voicemail, and get no response. I've emailed the MAA to ask what's happening.

Space being watched

airsound

wow, impressive response speed. Just heard from MAA that the SI will be published on the final day of the inquest. According to the Lincs Coroner's office, that will be 31 Jan.

Avtur

14th Jan 2014, 12:18

I know nothing about ejection seats, so silly question time: Is there any electronics in the firing system that could be initiated by mobile phone RF (EMI)?

Although there was mention of him taking a call when walking out to the jet, I didn't see any statement/confirmation if the phone was "on" post accident.

Absolutely terrible whatever the cause.

Biggus

14th Jan 2014, 12:26

Avtur,

Kindly read the whole thread........ especially post 37!

Courtney Mil

14th Jan 2014, 15:22

Well, not everyone always reads every thread all the way through, especially if one has missed a few days or has come into it cold. So the easier answer might be "No". Not as far as we know. Post 37 does give a good answer.

Biggus

14th Jan 2014, 15:30

CM,

It's a thread that's still on its third page, with only 50 odd posts - not a long read.

I did say "kindly", refrained from anything more pointed, and even steered the person directly to the answer, so avoiding them having to read all the posts if they so desired....

I consider my response to have been very reasonable by average pprune standards!!

Avtur

14th Jan 2014, 17:17

Cheers Biggus and yes it was a reasonable response; I only skimmed the posts.

Rigga

14th Jan 2014, 17:47

Dtyke said:
/"Here's a fact for you. In the 80's that shackle would have been testedinspected in the ejection seat bay every 6 months. It then changed to every 12 months, then it changed to every 24 months........ no idea what it is now (they were talking 5 yrs when I left the RAF). I also believe all the unit ej seat bays are now shut down and seats are now crated up and serviced in one location. When I worked in ej seat bays (3 tours) it was not unusual to be called out to sqns for a 2nd oppinion on things the sqn armourers were not happy with, this is not possible now."

Extension of inspection periods is mainly based on the reliability of the subject area - If no faults were found in all those inspections you quoted why not extend them?
Likewise, if you have good data to show that you have found nothing significant after two or three inspections of the same articles - your inspection rate (and possibly your whole maintenance program) needs to be reassessed.

I believe that centralised seat servicing (at Marham?) had proven to be quite a cost saver for the RAF

Dominator2

14th Jan 2014, 17:51

Well Courtney, That's put you in your place. Obviously, that helpful, friendly place that we used to work at has changed. Must be that QF* mentality to never answer a question, just in case that answer is wrong! Ask another question and then claim it is to help educate the poor soul.

Dominator2

14th Jan 2014, 18:01

Rigga,

I cannot agree with you when talking about safety critical items. Otherwise, the first failure could cause loss of life. Through over 40 years in aviation I could site countless accidents caused by an item that failed unexpectedly. The fact that you think that saving money justifies cutting Safety Critical Inspections is fundamentally floored. It is about time that some people realise that aviation costs money. Some things cannot be brushed over or diminished, otherwise it will cost lives.

goudie

14th Jan 2014, 18:03

Good point Rigga. There was a time when, on a major servicing, just about every component was removed and tested. Rarely was anything found defective, though the removal and re-fitting often created faults.
Dominator 2 Safety critical components were, of course, a different matter.

Courtney Mil

14th Jan 2014, 21:07

It's OK, Biggus, I wasn't really having a go. I just thought "NO" was an easier answer. And, Dom, I am as ever back in my place, as you say - good call. But probably not for long :E

Here's a thing, though. If we can't use mobiles on garage foecourts in case they make the pumps explode (I know, I'm being flippant), could a strong RF signal trigger a detonator? Probably not in my view, but has anyone tested it?

As for a teaspoon full of Night Nurse last night, really? One might ask if he had flu, but I think someone might have noticed and the man was certainly smart enough not to press like that.

Maybe a good deal of speculation from somewhere that only suggests an eargerness to get the fisrst "told you so" headline at the expance of a bloody good aviator.

AR1

14th Jan 2014, 22:22

The concerns regarding garage forecourts and Cellular devices is related to potential sparking of antenna connections and vapour. - Intrinsically safe RF devices used for example in a bomb dump would have encapsulated circuitry in addition to low power outputs, Cellphones don't however depending on technology and mode the power is not massively over the 500mw (IIRC) that was the IS device power rating.

DITYIWAHP

14th Jan 2014, 23:15

Slight thread drift, I know... I think that banning the use of mobile phones on garage forecourts is only prevalent in the UK (and maybe the EU??). Certainly no one in the US cares about this theoretical risk - which is probably the RF equivalent of making everyone on a military flight line wear yellow safety jackets.

layman

14th Jan 2014, 23:41

From RAC Victoria
Mobile phones and fuel fires | Motoring | RACQ (http://www.racq.com.au/motoring/cars/car_advice/car_fact_sheets/mobile_phones_and_fuel_fires)

"Investigations into refuelling fires in the USA conducted by the Petroleum Equipment Institute concluded that, rather than mobile phone radiation, 90 percent of them involved static electricity discharges of some type. In the remaining 10 percent the cause was inconclusive.

The research concluded that while there is theoretically a very slight possibility of a spark being produced by the battery in a mobile phone, the likelihood of a phone-induced fire was negligible."

Back to the topic ...

I met Sean once, many years ago, and have a relative flying aircraft with similar seats, so am interested in the outcomes here.

I've read the thread, and hope I haven't missed this, but is there a timeframe for publishing the coroner's report? A week / month / 6 months?

thanks
layman

dctyke

15th Jan 2014, 07:01

All the carts on that seat are percussion fired, a mobile phone would make no difference in this particular case.

Rigga, I have no issue with componants and equipment which are extended due to testing etc. My issue is 'footfall' in and out of the seat which has the potential for damage to the componants on the seat which increases over extended periods. For example the amount of dirt from the underside of boots/shoes that collects in the seatpan can be considerable even after just six months. Also the longer the seat is in the longer it is subject to weather, the canopy does not always get closed before the rain arrives!

The extention to seat servicing and centralised servicing was to save money, lets not kid ourselves it was anything else.

charliegolf

15th Jan 2014, 07:20

Would that perhaps simply have been part of a very general summation of his movements and activities in the hours before the sad event, and nothing more? Is there even a sniff of a suggestion that he was 'drugged' before flying? And are service cynics (I am a civi cynic) really worried he will be found culpable because of it?

CG

Q-RTF-X

15th Jan 2014, 09:23

Always provided suitable covering/protection measures are in place and adequate transit arrangements made then I cannot see any great problem in a system of centralized servicing. As a plus, it certainly places a good pool of focused technical expertise in one place. In the early 60’s I remember removing seats from Canberra T4’s (a pig of an installation btw) after which they were transferred a couple of miles to/from the seat bay in the back of a land rover usually resting on the vehicle seat cushions (or whatever else may have been handy); hardly the best way and in all probability the transport arrangements nowadays to/from Marham will be a considerable improvement. Provided appropriate arrangements are in place for the transit, I cannot see a great issue with centralizing the servicing and if a wad of cash can be saved then one should do so. As to time cycles between inspection/life of critical components, I am now a little too remote to comment.

Tashengurt

15th Jan 2014, 11:18

People seem to be in an awful flap at the mention of meds and mobiles.
A coroners court is like a sponge. It'll soak up all kinds of information and some will be irrelevant, some trivial and some important. Some may even be red herrings.
It's only right that all the details get considered or accusations of a cover up or incompetence will fly.

Posted from Pprune.org App for Android

NutLoose

15th Jan 2014, 11:21

Courtney, I think you will find during refueling and using a phone it may be static that is the issue or simply the phone is not intrinsically safe, ll the electric devices in gas stations are protected with explosive containment devices, mobiles will not be.

I remember we used to do rotor turning refuels on Wessex whilst plugged into the intercom, however tests were carried out and it was found that there was so much static floating about because of that, the potential was there to cause a spark, hence the on intercom refuelling was forbidden after that.

langleybaston

15th Jan 2014, 11:42

Static! Every time Mrs LB stepped out of our previous car and went to shut the door there was a mighty static spark and a mighty wifely oath [decorous within the total range of possible oaths].

The spark could be SEEN at night. Rather outweighs the moby possibility one would have thought?

Rigga

15th Jan 2014, 12:00

Dtyke:
"I have no issue with componants and equipment which are extended due to testing etc. My issue is 'footfall' in and out of the seat which has the potential for damage to the componants on the seat which increases over extended periods. For example the amount of dirt from the underside of boots/shoes that collects in the seatpan can be considerable even after just six months. Also the longer the seat is in the longer it is subject to weather, the canopy does not always get closed before the rain arrives!"

I'm not picking on you Dtyke, just answering the post.

If your inspection periodicity covers this exposure to damage and you're still not finding faults then there is no real issue in considering extending the period.

Safety Critical Component inspections can be extended by the right TC holder. e.g. Boeing deleted all the periodic inspections of some 737 APUs from their AMP (including oil changes) as the inspections didn't prevent anything happening.

Blacksheep

15th Jan 2014, 12:46

Is this staffing level shortage indicative of the RAF squadron strength as a whole? It was in 1977, which was the main reason I elected to leave at the end of my first engagement. I can't imagine that the situation has improved in the meantime. One of the Royal Air Force's principle weaknesses was a strong "press-on-regardless" culture - it's tough but we can hack it!

As a Continuing Airworthiness specialist I make two observations:

1. The cause of the ejection is difficult to determine. I do recall the Harrier that flew on over the sea, perfectly trimmed, until it ran out of fuel. The seat and pilot were missing - unintentional ejection?

2. The cause of death in this accident is perfectly clear - once activated, the ejection seat failed to operate as designed.

How was the seat accidentally activated and why did it then fail to function properly? The BoI, when it takes place, should focus firmly on those two points. Self medication, mobile phones and other such distractions have nothing to do with the defect in that seat.

Dengue_Dude

15th Jan 2014, 13:13

How was the seat accidentally activated and why did it then fail to function properly? The BoI, when it takes place, should focus firmly on those two points. Self medication, mobile phones and other such distractions have nothing to do with the defect in that seat.

You're actually on dangerous ground there Blacksheep and the BOI are well aware of what they need to be looking at. Suffice to say a huge amount of work has gone on in the background since the accident.

Nige321

15th Jan 2014, 13:41

From yesterdays Lincolnshire Echo:

Here (http://www.lincolnshireecho.co.uk/Sean-Cunningham-Red-Arrows-inquest-chute-bolt/story-20428182-detail/story.html#ixzz2qThas7rg)

As important nuts and bolts go, this is an important one. Is it really true there was no torque guidance in the manuals...?

Maintenance instructions for Red Arrows ground crew working on ejection seats gave them no proper guidelines on a crucial nut and bolt.

When ejection seats are fired a drogue parachute deploys in order to stabilise the descent.

This mechanism then allows the main parachute to release.

When the pilot activates the seat, a plunger releases the arm of a scissor shackle and in turn releases the drogue shackle the first chute is attached to.

It is crucial that the nut and bolt through shackles is not over-tightened, which could prevent it working properly.

Questions over the bolt's performance were raised during the inquest into the death of Flight Lieutenant Sean Cunningham.

He died on November 8, 2011 after his ejection seat was fired while his plane was on the ground at RAF Scampton.

Reds armourer Sergeant Chris Clarkson, who was present when Flt Lt Cunningham ejected, but has since left the RAF, told the court he understood the drogue nut and bolt should be tightened to a “good positive lock” and showing at least one and a half threads.

He said: “The head of the bolt is very thin.

“It’s difficult to get the spanner on it especially with it’s location on the under side of the drogue.”

Hugh Davies, QC, for Lincolnshire Police, asked: “Did you understand that if the nut was tightened too far it would prevent eventual release?”

Mr Clarkson replied: “I was not aware of that at all.”

Bernard Thorogood, counsel for the Health and Safety Executive, read this extract from the workshop manual that guided the armourers: “Pass the bolt through the drogue and scissor shackles and secure with a lock nut.”

He told the court: “In the absence of any more direct instructions such as torque, that’s the instructions that mechanics or armourers would follow.

“That’s what brings us to think about one and a half turns as a basic engineering principle.

“The problem with that sort of instruction is it involves a subjective amount of judgment by whoever is tightening the bolt.”

The inquest continues.

Mr Clarkson said he did appreciate that when an ejection seat fires the drogue needs to separate from the scissor shackle.

Read more:

NutLoose

15th Jan 2014, 15:05

and showing at least one and a half threads

Standard securing in case you do not know to ensure a nut and bolt are in Safety.
For your Info,The US have a different take on the amount required to be showing though, it being less.

It's been so long since I touched a Military Jet, but the Civilian side of things, if a torque is not specifically mentioned, there is normally a chart in the front of the manual with generic torque settings for standard nuts and bolts, however, one suspects the shackle bolt was not a standard item.

tucumseh

15th Jan 2014, 16:13

Bernard Thorogood, counsel for the Health and Safety Executive, read this extract from the workshop manual that guided the armourers: “Pass the bolt through the drogue and scissor shackles and secure with a lock nut.”

Many types are 100% replacement items. The visible thread guidance would only be valid in conjunction with it being replaced with a new one. Lost count of the times stores didn't have one and pressure was applied to re-use.

-re torque, on one notorious occasion Boeing didn't specify torque loadings to their own people, never mind the RAF. An avionics rack in a new Mk2 had been over-torqued so badly the honeycomb bulkhead was crushed to nothing, and fully laden with LRUs it toppled onto a UK contractor, minutes after touch down from its delivery flight. MoD denies the incident occurred, despite he and witnesses who reported it retaining their reports.

I also recall MoD denying a critical component was manufactured wrongly, causing multiple deaths. (ZA721, 27/2/87) The AAIB invited anyone interested to speculate where the split pin would be inserted, given no hole had been drilled. MoD ignored the evidence and said cause not determined.

Point being, MoD have form when it comes to protecting certain protected species, both companies and individuals. I hope the Coroner spends his 3 weeks digging deeply, but allowing MoD to withhold SI reports, thus denying informed questions, is not a good sign.

dctyke

15th Jan 2014, 18:33

Interesting that the German Air Force chose to pay Aeroflug to replace the MB scissor shackle assy's on their Mk10a Ejection Seats with their own design. The site does not state the reason.

See just over half way down the page.

http://www.ejectionsite.com/frame_sg.htm

Mortmeister

15th Jan 2014, 20:07

Having spent 6yrs on Hawk and same on Tornado during a 24 yr career as an Armourer I am very familiar with the Mk10 seat. The statement from the Armourer SNCO from the Reds is correct. The AP used to contain a statement to the effect of 'tighten the stiff nut until 1 1/2 threads are visible through the nut' or words to that effect. This was checked on both the Vital and Independent checks.
I have always felt that the failure to release in this accident must have been caused by this stiff nut being overtightened, as this would prevent the Scissor Shackle from opening correctly.
As for why did the seat fire in the first place? The Seat Pan Firing Unit sits very close to the cockpit floor when the Seat Pan is motored down on its Actuator. A reasonable size loose article (for example a Mobile Phone) could be enough to dislodge the Sear in the Firing Unit and initiate the ejection sequence.
As rightly pointed out by other posters, serious accidents are often caused by several events lining up to cause a disaster (Swiss Cheese Theory). If they were operating at reduced manpower and/or experience levels, that could explain why an otherwise very reliable system has been catastrophically compromised, leading to tragic results.
I am convinced some people in the service will know the cause of this tragedy, I hope it will come out.

BEagle

16th Jan 2014, 07:36

A reasonable size loose article (for example a Mobile Phone) could be enough to dislodge the Sear in the Firing Unit and initiate the ejection sequence.

For all its high-tech cleverness, the M-B seat has never been as totally 'safe' with pins fitted than was the Folland seat in the Gnat. That used a physical interruptor plate which prevented anything striking the cartridge and firing the seat when the lever was at 'safe'....... Simple and totally reliable.

jimgriff

16th Jan 2014, 07:56

Does anyone know why the Aeroflug mods were done to the German seats? Was it an 'improvement' or a reaction to a perceived weakness in the original design by MBA?

lightningmate

16th Jan 2014, 16:08

Beags,

Point taken, but if the firing path is 'mechanically interrupted' as a safety means, there must always be a concern that despite setting the arming mechanism to the correct 'live' position the interrupt remains fully or partially in-place. This situation may or may not deliver a tactile feedback to the operator to warn of the problem. As we are all routinely reminded, the impossible occurs.

Hence, there is a design issue to be considered in terms of minimising any risk that the seat would not fire when needed and MB has opted to keep the primary firing path for their seats open at all times.

lm

Dave Haggas

16th Jan 2014, 21:46

I am reading this with interest as I am currently stripping and rebuilding a couple of MB mk 9 seats from a Harrier for a museum.
I have, tonight just installed the shackle bolt which does have a shoulder. This means you cannot over tighten if common sense were applied. If I were to use another bolt with a shorter shoulder it could easily be clamped, rather than a loose fit. If however a nut that perhaps had a counterbore on its inside or indeed was over tightened, I would say that would also cause an issue. It is interesting to note the comment that the correct bolt has a short head. This is true for the Mk9 seat and you simply use a cranked ring spanner. If you lift the scissor shackle up it really is not an issue to fit a spanner.
Regarding torque settings, I will check the manuals that I have and report back.

Easy Street

18th Jan 2014, 22:22

It's been a while since I flew in a seat with the Hawk-style scissor shackle, and would appreciate a reminder from someone with more recent experience. I have vague recollections of wiggling the drogue shackle during the seat checks, expecting to find a little movement. Would this have been aimed at discovering the fault that appears to have killed Sean? In recent years I've heard people discouraging the practice of touching seat components during the checks, but to my mind the shackle and the top latch (incorrectly engaged in Wolfy Harland's accident) were two parts that could best be checked by feel. What is the current advice and practice?

Avtur

21st Jan 2014, 03:04

There's a live synopsis of the proceedings here.

Excellent while it lasted (thank you): Is this going to continue, or is it now "old news", and no longer worthy?

Background Noise

21st Jan 2014, 09:09

No, it was a twitter feed from a Lincolnshire Echo reporter and he was only covering the sensationalism of the first 2 days.

Nige321

21st Jan 2014, 09:58

From the Lincolnshire Echo

The inquest into the death of Red Arrows pilot Sean Cunningham heard that life critical safety warnings about ejection seat maintenance were first issued to foreign air forces more than 20 years ago, but not the Ministry of Defence.

Seat manufacturer Martin-Baker Aircraft Co. Ltd advised the Pakistan Air Force in 1990 not to over-tighten a key nut and bolt in the seat mechanism.

Over-tightening can cause pinch and lead to the parachute failing.

The instruction was to ensure some free play in components and have one to one-and-a-half threads showing through the nut.

Similar advice to other air forces including India, Italy and Finland followed.

Richard Seabrook counsel for the Coroner, put questions to Michael Cameron, Martin-Baker’s senior after sales executive, who was the company’s chief technical instructor from 1999 to 2008.

Mr Seabrook asked him: “You cannot explain why advice particularly relevant to the MoD was not communicated to the MoD at or about the same time [as foreign air forces]?”

Mr Cameron replied: “I cannot explain this but it was nine years before I got there.”

Mr Cameron said that until Flt Lt Cunningham’s death he was unaware of the risk of the mechanism pinching if over-tightened.

Bernard Thorogood, for the Health and Safety Executive, said the concern about over-tightening was a “risk to life” issue.

Mr Thorogood asked Mr Cameron: “There was concern in 1990 about the thorny issue at the heart of this inquest.

“This should have been passed onto customers?”

Mr Cameron replied: “Yes.”

Mr Thorogood then put to him: “This should have been dealt with in a way that left customers in no doubt?”

Mr Cameron replied: “Yes, but I was not there at the time.”

The court heard that after the accident it was discovered the key bolt in the mechanism in Flt Lt Cunningham’s ejection seat appeared to have bent in operation.

Asked what conclusion he drew from this, retired Martin-Baker engineer Neil Mackie, who worked in its quality assurance department, replied: “Vastly over-tightened.”

Flt Lt Cunningham died after his ejection seat fired from his aircraft while it was on the ground at RAF Scampton on November 8, 2011. His main parachute failed.

The inquest continues.

Read more: Sean Cunningham inquest: foreign air forces were given ejection seat safety warnings more than 20 years ago, but not the RAF | Lincolnshire Echo (http://www.lincolnshireecho.co.uk/Sean-Cunningham-inquest-foreign-air-forces-RAF/story-20471627-detail/story.html#ixzz2r1tSFMJR)

The inquest heard of the ongoing work to improve ejection seat safety.

Martin Lowe, the Ministry of Defence head of engineering, for aircraft escape systems and a former RAF chief technician, said that there is a proposal from ejection seat manufacturer Martin-Baker, at his request, involving a re-designed drogue shackle nut and bolt within the seat mechanism.

Mr Lowe said this is effectively a shoulder bolt, beyond which the nut cannot go.

This would make over-tightening impossible and therefore avoid the risk of the parachute not come out.

It is anticipated that the new nut and bolt and a special tool will be introduced by May or June of this year.

Mr Lowe also said a small metal plate is being developed to help prevent pilots inadvertently activating the ejection seat firing handle.

He said the plate has five benefits.

It prevents the safety pin being inserted while the seat firing handle is in the unsafe position and there is a groove to help guide pilots with insertion.

The plate also stops the handle being pushed forward to complete the ejection.

Inadvertent insertion of the safety pin between the handle and the housing is averted and harness straps should not snag on the handle.

This measure is due to be in place by the end of this year and will apply to Hawk T1, T2 and Tornado jets and the Tucano trainer.

Read more: Sean Cunningham inquest hears of ongoing work to improve ejection seat safety | Lincolnshire Echo (http://www.lincolnshireecho.co.uk/Sean-Cunningham-inquest-hears-ongoing-work/story-20445900-detail/story.html#ixzz2r1u3polk)

The Old Fat One

21st Jan 2014, 11:39

Given that the RAF/MOD have in the very recent past been down a very similar road it's becoming pretty obvious where this is headed and what's coming next, albeit perhaps on a smaller scale (but given the PR context -maybe not).

airsound

21st Jan 2014, 11:52

Following on from Nige321's above, there's actually quite a lot in the Lincs Echo:
Lincolnshire Echo | Search on Lincolnshire Echo (http://www.lincolnshireecho.co.uk/search/search.html?searchType=&searchPhrase=sean+cunningham&where=)
Sadly, they've stopped the live-ish tweets, but they seem to be covering the inquest most days.

BBC Look North (Yorks&Lincs) say they plan to have a reporter there every day - so far Caroline Bilton's reports have been pretty good. You can find that version of Look North on Chan 957 on Sky, not sure about other providers.

Although the MAA will not publish their SI until the last day of the inquest, Cdr Danny Stembridge, of the MAA, is due to give evidence on Thu 23rd.

The last planned day for witnesses is Tue 28 Jan, then the Coroner takes a day or two to write up his findings.

airsound

Mortmeister

21st Jan 2014, 12:13

So how, or why was I (and many others) instructed to leave only 1 1/2 threads showing through the stiffnut and check for movement in the scissor-shackle from 1988 until 2000?

Must have imagined it?

tucumseh

21st Jan 2014, 16:10

It doesn't say in the above extracts how it was established MoD did not get the information. Is this an allegation by MoD, or has MB accepted it as true? All the MB guy has said is he wasn't there at the time, which is not the same as admitting the info was not passed on.

It would certainly be a handy "out" for MoD if true. But in my experience, in that period, it is equally, if not more, likely that MB has passed on the info properly and it has not been disseminated correctly; largely because the mechanism was run down in the period 1990-on. Bear in mind the same system allowed captured Argentine publications and maintenance data to be used on Chinook, which says it all.

The key process is one of informing "affected parties", and any reputable company keeps this data up to date and permanently embedded in the necessary "advice notes", or whatever. For example, in a MF714/5. The MoD department that oversaw and policed this fundamental airworthiness principle was disbanded in June 1993, and not replaced in any shape or form. Thereafter, it became pot luck whether the Engineering Authority, Pubs Authority or Project Manager was on the ball. As Mortmeister correctly implies, some would know and others wouldn't.

Even if, somehow, MoD was left off distribution, so critical was the issue that MoD's resident QAR would be climbing all over them. That is, if it happened before these posts were cancelled as a savings measure.

There is a lot more to this but I'm certain the MoD won't trot out any witness who can dissect the issue, and the Coroner won't know what to ask.

dragartist

21st Jan 2014, 16:23

Mort,
Words are easily confused. Did you leave "only" one and a half threads or "at least" one and a half threads.
As a teenager my dad gave me his 1950s fitters notes (AP****) I still have them in the garage. I am guessing that we are of an age where we take our basic training for granted and don't need telling the obvious.

The number of threads protruding is no indication of the tension in the bolt.

I saw a description of the bolt in an earlier post describing a thin head. implies a sheer bolt. years back it was more normal for these to have castle nuts and spilt pins rather than the stiffnuts shown in the pictures in todays BBC video. In this case they should allow the assembly to rotate freely. difficulty torque tightening stiffnuts. particularly if they were reused. heard a number of myths in my time over how many times they could be reused anyway. just chuck them and use new each time for the sake of a few pence.

No one has said if these are standard AGS/BS items. Martin Baker had the habit of issuing their own part numbers for standard bits anyway.

Sad affair. lets hope they come clean and get to the bottom of the problem and share the findings so lessons can be learned.

reading the transcript I wonder why Mr Cameron [of MB not the other one] feels the need to defend Himself by saying it was before his time rather than just present the evidence or give his expert opinion.

Flight_Idle

21st Jan 2014, 17:44

Just an old airframe guy here, but with 'Fork ends' etc where one had to avoid 'Squeezing' a shouldered bolt would always be used.

Basic stuff which could be finely machined to suit the apparatus. I just don't get the ordinary bolt being tightened to a certain level on something which is supposed to move.

Not my speciality, but it makes me think.

bvcu

21st Jan 2014, 17:45

My question is what was the reason for issuing this info to these customers? Was there an accident or something found with these customers ? Only Finland had Hawks with MK10 seat. Others had Mirages/Hunters/Canberras with earlier MB seats.

Mortmeister

21st Jan 2014, 18:53

Drag artist,
We were instructed to do the stiff nut up to only allow 1 1/2 threads showing (ie achieve locking), but crucially ensure that the scissor shackle remained loose.

When tightening the nut, it is true that the base of the bolt was thin and that holding it with a spanner was difficult until you had mastered the correct way of achieving this.

You have hinted at a valid point though, how much engineering training do SAC weapons guys get these days? Don't forget, ejection seat work used to be carried out by Junior Techs as a minimum and is now done by SAC Techs. There may be something there, but I would not like to cast doubt on the tradesmen doing the job, as I have no experience of current standards. However, this critical link would be checked on vitals by the supervisor and independents by an SNCO.

goudie

21st Jan 2014, 19:10

Murphy's law is an adage that is typically stated as: Anything that can go wrong, will go wrong.

From what I've read here and if true, regarding possibly over-tightening the stiff nut, it would seem that unfortunately, 'Murphy's Law' is alive and well.

Just This Once...

21st Jan 2014, 19:37

We were instructed to do the stiff nut up to only allow 1 1/2 threads showing...

So if we understand this correctly, by following the APs and your instructions you also overtightened the bolt, just like a tradesman of today would?

dragartist

21st Jan 2014, 19:38

Mort, Don't wish to enter a willy waving contest over bolts. Your way would mean that the overall bolt length and also the thickness of the nut was extremely critical. too long bolt- too thin nut and it would float. too short bolt and too thick nut, insistent one and a half threads that could be two; could pinch. The critical test would be the rotation rather than the number of threads protruding.

I only did just over 35 years including 14 as the EA for some similar kit. I worked with Martin Lowe for a spell. I certainly noted the erosion of engineering support staff over the years in that team. Under his name sake The safety managers post migrated to become some sort of Business Manger. even became manned by a blanket stacker shortly afterwards (a fine one mind). The guys down in the old billet blocks at Wyton who came from CSDE etc were disbanded. the posts were supposed to be absorbed by the IPTs but no one wanted the head count on the MCT

Contrary to what Tuc states about 714/715 we continued to use the forms and process well into the mid 2000s, probably at the insistence of the last Gp Capt IPTL* we had. Including completing all the Cost and Brief sheets and providing the safety argument with evidence to support his signature on the Mod.

* Great bloke went on to do something in swimming.

As Tuc also states we would have had a RPO or at least a VPO/ PDS officer and the DGDQA support who would turn up like clock work to LTCs/ Mods Ctee/PDS meetings etc. They would know the kit intimately. I figure we leaned so far we fell over. And the consequences... well we spend so long reminding ourselves about them on here.

It would not really be right for me to comment on the skills of these SAC Techs over JTs working on this kit. however in my line of business (not bang seats) I certainly noted an erosion in skills and competence over the years manifesting itself in lost sorties, incomplete and broken kit, some very poor husbandry. I made myself very unpopular grumbling about it for over 30 years. Pleased to be away from it in some ways. Now I am consumed by the build up of struvite in pumps. Could not be further away from planes.

Photoplanet

21st Jan 2014, 20:02

Murphy's Law has no place anywhere near ejection seats. It's been a few years since I was working on Tornado F3s as an Airframe Technician, but the reverence with which the seats and associated systems are treated by the groundcrew should not be underestimated.

I would seriously doubt that the tightening of a scissor shackle bolt would be the last stage of seat servicing in a bay. Whilst I would not wish to pre-empt any coroner's findings, I would be shocked if it turned out that the scissor shackle bolt had been tightened to the extent that it was the only thing preventing the parachute deploying.

The cause of the ejection sequence itself will hopefully be revealed, and lessons learned.

downsizer

21st Jan 2014, 23:01

I can't find any reference to it this far, so have they discussed what/how the seat was actually initiated...?

Plastic Bonsai

21st Jan 2014, 23:22

The second quote in Note #85 suggests someone has found several ways to inadvertently fire the seat though surely it would have happened before now if it was possible?

I've seen no mention of the state of the seat pins, or any suggestion at what Flt Lt Cunningham might have been doing at that moment or what stage he was at in the start up sequence.

cockney steve

21st Jan 2014, 23:38

WRT the M B witness' "I don't know, I wasn't there"....
As others have hinted (or maybe i read something into it)
the man works for MB
MOD is obviously an important customer
there are other Bang-seat manufacturers
anyone in MOD who may bear a responsibility for poor systems/safety procedures, may also have influence in specifications for purchasing.

To put it bluntly....the MB staff are going to be somewhat circumspect when it comes to rocking the boat...they are unlikely to deliberately cause a major embarassment to one of their major profit-sources.
Motor-car seat-belt mountings, by numbers, have far more events than bang-seats...one does not hear of fatal crashe caused by seat-belt failure....where fittings have to have movement, there are stepped bushes / shouldered bolts/ spring-washers /fibre washers to ensure that, according to design and purpose, a belt can be removed/checked/refitted by a relatively unskilled person
yes, some designs have a very thin head on a stepped bolt...they get dogged-up tight...if the retained part is meant to move, it does..if it's meant to be rigidly fixed, it is.

there's a whiff of arse and back-covering here, IMO.

NutLoose

22nd Jan 2014, 00:03

I must admit, when they initially realised there was a problem you would think they would have warned all the operators immediately and redesigned the bolt as a matter of urgency.

I can understand the visible thread issues, but I don't know, maybe there is a clearance problem with getting a torque wrench in, hence using visible thread as a guide...

Sadly this also deflects from the issue of why the seat fired.... That needs to be addressed because it's not just an issue when the seat is needed, but an issue when anyone accesses the cockpit.

downsizer

22nd Jan 2014, 00:19

Yes to my eye there are two issues here, the overtightening of the bolt and why the seat fired in the first place.....:sad:

I have a theory but I don't want to add any fuel to any fires....

tucumseh

22nd Jan 2014, 06:33

Contrary to what Tuc states about 714/715 we continued to use the forms and process well into the mid 2000sEh? I didn't say MF714s weren't used anymore. I said that, when making a proposal (714) one is required to answer the question as to affected parties or contractors. For many years PDS contractors have held the 714 as an electronic file with that field completed automatically from a database which records who uses each of their products. So, if any information requires distribution, you simply call up that "address book" folder, same as in an e-mail programme. The contractor is required to maintain that database, under MoD contract. One question is this - Was that contract continuous? Without it, the safety case becomes progressively invalid. (Same as on Nimrod etc) -

The process for ensuring independent scrutiny and approval of 714s was disbanded by the Chief Engineer in June 1993. I chaired the last avionics committee. At the same time, he stopped routine updates and maintenance of MoD's equivalent databases e.g. the Avionics List, which was how MoD staff found out what was fitted to what platform. He introduced "self assessment and approval" which, because it ran contrary to SoS's and PUS's mandated requirement for independent scrutiny, is why the relevant regulations were never updated; D/Stan couldn't find anyone to put their name to a policy that contradicted SoS or PUS. In the end, they gave up and the Def Stan was cancelled without replacement (yet is still mandated, despite MoD no longer having a single copy!) Hope that clarifies.

lj101

22nd Jan 2014, 06:35

Maybe the pin wasn't put backin place after its last flight, despite engineers servicing the jet during the period until the next flight, the error wasn't picked up. Maybe subsequently the straps were caught around the handle when he strapped in.
Maybe MB were aware that there was a problem with that part having been picked up on other ejections albeit forward speed ones so the seat worked on those occasions but a zero zero ejection may have been a issue. Maybe MB didn't warn of this issue. Who knows - it can be a murky world protecting corporate images.
Just my thoughts having screwed up myself with the pin during training. I was physically sick when I realised what I had done.

Plastic Bonsai

22nd Jan 2014, 07:24

These seats are designed to work at zero-zero.

It is likely that Flt Lt Cunningham was fully strapped in when the seat fired.

Given how important and how much it is drummed into everyone about ensuring the seat is made safe and enabled you would have thought it was very unlikely that the seat would accidently fire in normal everyday circumstances.

The Taylor-Scott accident put a focus on ensuring the seats could not be activated by objects falling beneath the seats - at least on Harriers IIs and I presume all other similar designs?

Mortmeister

22nd Jan 2014, 07:52

If the nut is tightened correctly (leaving 1 1/2 threads visible) the scissor shackle fits perfectly. If you overtighten the nut the scissor shackle gets compressed and that is what some of us feel is the issue here.
Yes, a shouldered bolt would potentially prevent this, but it would be up to the boffins at M-B to analise and sanction that kind of change. They may well have had their reasons for using this assembly. To be honest, the basic design of that assembly had not altered much over many years and I understand Typhoon and Lightning II seats are significantly different in this area.
Just to inform, this operation would not be carried out in a Seat Bay, but would have been carried out by 1st line armourers during the act of fitting the parachute headbox.
For what its worth, I would still rather have a M-B seat than any other!

lj101

22nd Jan 2014, 08:40

Given how important and how much it is drummed into everyone about ensuring the seat is made safe and enabled you would have thought it was very unlikely that the seat would accidently fire in normal everyday circumstances.
Agreed - but if the pin wasn't in place properly. I've been in that situation albeit without the same consequences due to the sharp eyes of the engineer assisting me strap in.
Mistakes happen.

Just This Once...

22nd Jan 2014, 18:52

If the nut is tightened correctly (leaving 1 1/2 threads visible) the scissor shackle fits perfectly.

Mort, you keep saying this but you must explain your reasoning as it contradicts the evidence being presented by M-B to the inquest. Given your experience I am genuinely interested in what you have to say as the picture painted so far is of armours applying the technique listed in the publications but that the publication itself had been incorrect for decades.

The 1990 warning, which was not sent to the MoD, specified that the drogue shackle nut should not be over-tightened. Michael Cameron, after sales executive for Martin Baker, told the inquest that the issue of over-tightening of the nut was a potential risk to life. He admitted that the company should have made it clear to its customers what the problem was.
Mr Cameron, who served in the RAF for over 20 years before joining Martin Baker, said "I don't know what happened at the time."

The inquest has heard how aircraft manufacturers British Aerospace and McDonnell Douglas had raised concerns about the issue which was discovered during the assembly of Tornado jets.

Mr Cameron said the nut should be fitted so that it was "flush" with the bolt rather than having one and a half threads showing as written in the manufacturer's manual at the time.

Source: Ejection seat firm failed to warn MOD of Red Arrows safety flaw - Telegraph (http://www.telegraph.co.uk/news/uknews/defence/10584816/Ejection-seat-firm-failed-to-warn-MOD-of-Red-Arrows-safety-flaw.html)

Mortmeister

22nd Jan 2014, 19:08

JTO,
Having been away from this equipment for some years now, I cannot comment on the publications as they are today. All I have stated comes from memory, having not seen a Mk10 Seat AP for over 14 years.
I'm at a loss to think of another explanation for what happened. The Mk10 seat was/is very reliable, with an excellent track record.

Just This Once...

22nd Jan 2014, 19:23

Mort, I understand entirely but is there is a chance that you, like many others, were over-tightening the bolt to expose 1 1/2 threads because that is exactly what the incorrect maintenance manual asked you to do?

cobalt42

22nd Jan 2014, 19:28

Dragartist
No one has said if these are standard AGS/BS items. Martin Baker had the habit of issuing their own part numbers for standard bits anyway.

So does 'everyone' else but the Organisation or Original Equipment Manufacturer - OEM - assign the definitive Part Number which, with their Manufactures Code: NCAGE, CAGE, MFC, NSCM, etc. - however you wish to define it, provide the definitive item of supply identification and that is what is used during the NATO/National Codification process to assign the NATO Stock Number. All the 'other' Part Numbers and CAGE Codes will be identified as a secondary reference with the same NSN.

The Oberon

22nd Jan 2014, 19:47

Something is wrong here, when I was taught about nuts and bolts and the torquing and locking of same, the 1.5 pitches of thread was a fundamental rule not a specific, one off, manufacturers requirement. In other words if when any nut was tightened, if there weren't 1.5 pitches of the thread exposed, then the bolt was too short. I really can't see someone like M.B. requiring a nut surface to be flush with bolt end and therefore going against a basic engineering principal.

Mortmeister

22nd Jan 2014, 19:52

JTO,
I do not believe so, as once the bolt was secure through the Scissor Shackle and the Shackle attaching it to the Drogue Withdrawal Line there was always freedom of movement of the Withdrawal Line Shackle. If the Nut was too tight, the Withdrawal Shackle would compress around the Scissor Shackle and be stiff to move. The whole assembly was then secured with a string tie attached to the closure pin in the Parachute head box.

Alber Ratman

22nd Jan 2014, 20:33

The 1 1/2 to 3 threads is a generic statement. If the AMM / CMM states other dimensions or loadings, that statement shouldn't be used as the definitive direction. Same sort of thing happened with a Mk 10 TLP in 2007.. Not one of the best weeks I ever had (and I had it easy to the three people who signed the MMPs).

halty

22nd Jan 2014, 22:39

Having spent many years fitting seats at Saints during the 90's I like Mort recall the 1 1/2 threads on the scissor shackle and at times it was a struggle to achieve that but there was always freedom of movement, which I am pretty sure had to be checked for during vitals or indies, the MK10 seats were also fitted to the Sea Harrier.
As to what caused the initial firing of the seat, I recall an incident at Saints were I was called to a Hawk where the pilot was strapping in for a test flight after maintenance, I dont recall the initial reason why I was called but what I saw sent a shiver down the spine! the QRF box was through the seat pan firing handle and the pilot had strapped in not realising, the pin was still fitted but had he lent forward to remove it then then sat back would it have been enough to pull the handle? not sure, just glad we never found out.

Flight_Idle

22nd Jan 2014, 23:00

One of the best things I remember about the RAF, was that engineering officers & pilots would always give time to those on the 'Coal face'.

To blindly follow the 'Book' without question, written by those far removed, is a potentially dangerous thing.

Disregarding the book is dangerous for sure, but there has to be a two way communication.

Experience does count & unbelievable things do happen.

I still scratch my head & wonder why MB chose to use a non shouldered bolt on a scissor shackle.

RetiredBA/BY

23rd Jan 2014, 09:09

I may have missed it in an earlier post, but does anyone know if the firing handle was found to be out of the normal position when the seat was found, or if any abnormal harness routings were noted.

I still find it very hard to believe that regardless of any bolt thread "show" requirement that this assembly COULD be overtightened as every engineer working on the seat would most surely know how the scissor shackle was meant to function.

Or how anyone would enter a jet cockpit without first positively ensuring that the seat firing handle(s) and safety pin(s) were in position, so surely all must have looked absolutely normal as he boarded the jet.

This really is a most curious accident.

NutLoose

23rd Jan 2014, 11:42

I still scratch my head & wonder why MB chose to use a non shouldered bolt on a scissor shackle.

Only reasons I can think without looking at it are, you can't increase the diameter of the bolt because of fit issues, you cannot reduce the diameter of the threaded portion, because you would then reduce the nut size and diameter of the pin and hence the strength in that area.

Distant Voice

23rd Jan 2014, 13:00

Perhaps I have missed something, but what did the material evidence show after the accident. How much of the thread was shown?

DV

dragartist

23rd Jan 2014, 13:22

Sorry Tuc, did not mean any offence. must read more carefully next time.

the 714/5 process per 05-123 was sound. I saw it watered down in later years. each team appeared to want to devise their own process.

when I spent a bit of time in DD2 area DDSM6 we were very big on cross fertilisation. Unfortunatly the formation of IPTs and Business units knocked a lot of this on the head. there was a lot of corparate knowlege around RAE/DERA/and early Q2. Some may have said they were the consistency*. There attendance at LTCs was knocked on the head by the bean counters (yes I have to admit I may have been slightly guilty in going along with this rather than digging my heals in).
* I don't feel this is the case today however.

Same was true of the F765 process. This is where the folks at Kentigern came into their own. we had a real good guy. (and yes I did put him forward for an award after they were dispanded)

One comment re secondary references and NATO numbers - I agree with the comments made by Cobalt. This would be the case in an ideal world with competant people serving the department rather than their employer. My comments were based on my own real world experiences.

I do hope the truth comes out soon. By the sound of proceedings I fear that this just culture being banded about has been put back in the bottom drawer. I do hope I am wrong..... again

The Old Fat One

23rd Jan 2014, 14:48

DV

I'm not an engineer and know nothing about ejection seats, but is the inquest comment by Neil Mackie at the bottom of the first quoted paragraph at post 85 what you are looking for?

tucumseh

23rd Jan 2014, 15:53

dragartist

No problem. I agree with what you say and it is interesting that other areas saw the same approach by the CE. The entire process you speak of was disbanded by June 1993 in my area, and we had to seek other jobs because we had nothing to do. Or, we had plenty to do, but AMSO had pi##ed the money down the drain and stopped funding pubs, 765s, 760/1s, obsolescence, configuration control, mods, safety cases etc.

Co-incidence that this is the precise timeframe under discussion at the inquest? I don't believe in co-incidences; the same failures, at the same time, led to the "new" evidence on Chinook that MoD so arrogantly demanded for so long. Maybe that's why the MAA have withheld the SI report from the Inquest. Same old names cropping up.

Funnily enough, the HCDC has this week asked for evidence on this very subject. Interesting that they don't ask MoD..... One day the VSOs involved (AMSO/AMLs from 1985-96) will find their protection has disappeared! I notice one of them no longer posts here. Good riddance.

srobarts

23rd Jan 2014, 17:10

President of the inquiry at the inquest today:
Sean Cunningham inquest: snagged harness strap four days before tragedy led to ejection seat firing | Lincolnshire Echo (http://www.lincolnshireecho.co.uk/Sean-Cunningham-inquest-snagged-harness-strap/story-20488439-detail/story.html)

Further from today:
MoD was not told about key safety concern | Lincolnshire Echo (http://www.lincolnshireecho.co.uk/MoD-told-key-safety-concern/story-20484377-detail/story.html)

NutLoose

23rd Jan 2014, 17:39

Martin-Baker and the MoD are looking to roll out a new shoulder bolt in May or June this year to make over-tightening of the nut impossible.

Read more: MoD was not told about key safety concern | Lincolnshire Echo (http://www.lincolnshireecho.co.uk/MoD-told-key-safety-concern/story-20484377-detail/story.html#ixzz2rFRO2Hwr)

A stepped bolt will not make over-tightening a nut impossible, it simply prevents it from travelling any further thus retaining the correct spacing, you can tighten a nut until you strip the threads or snap the threaded portion off a bolt.

dragartist

23rd Jan 2014, 17:52

Nutty,
you are not wrong but we all know he knew what he meant.

I sit in amazement over how many column inches have been generated over a simple nut and bolt. (I was reluctant to join in to begin with)

the problem I have seen with shoulder bolts is that the thread gets undercut making them liable to sheer off if over tightened.

May be better to use a spacer tube. but I have not studied the assembly and constraints.

Let us hope what ever happens they get the books clear so there can be no scope for variation. In the Auto industry we used the term Poke Yoke to describe things being fool proof. I did a course at the Smallpeice Trust at Warwick a while back.

Drag

cornish-stormrider

23rd Jan 2014, 19:00

Call me a cynic but from what I read in the press the conclusions being drawn are that Flt Lt Cunningham f**ked up FOUR DAYS previously, in how he strapped in/unstrapped/safed the seat.

19 separate entries into the cockpit "missed" the unsafe seat.
Flt Lt Cunningham then missed it again on strapping back in and after pulling the pin he sat back and the seat fired.

I call bollocks on this, I am detecting a strong whiff of someone being scapegoated to save face of VSO, once again.

20 separate people do not miss the fundamental safety checks on seats....

Back when I learnt about seats as a humble liney I, like everybody else was taught that you are climbing on a bomb, one that wants to fire, one that wants to kill you and will do so if you do not give it 100% respect for every single second you are working near it.

when I had my backseat trip - the scariest part for me was removing that seat pan pin when the pilot commanded me to.

I do not believe Flt Lt Cunningham f**ked up - besides, whatever caused the seat to fire - the fact it malfunctioned which led directly to his untimely death needs to be fully investigated and made sure will never happen again.

this process needs to leave no stone unturned. Sadly it looks to me like the ole VSO wagon circling and MOD intransigence (sp) will win.

Again:ugh::ugh:

Just This Once...

23rd Jan 2014, 19:04

cornish, that is a bit harsh and does not fully reflect the facts.

longer ron

23rd Jan 2014, 20:17

Yes the technical investigation was in depth and extremely thorough,there is no need for any of this speculation - especially at this late stage in the proceedings !
This was always going to be a difficult one but surely worth sitting back and waiting for the report to be published before making sweeping statements on here !
As others have said - the findings will be published shortly.

rgds LR

longer ron

23rd Jan 2014, 20:21

when I had my backseat trip - the scariest part for me was removing that seat pan pin when the pilot commanded me to.

Similar for me...It was a little strange removing the seat pan pin after all those years of ensuring it was firmly fitted ...
It got easier with subsequent flights : )

tucumseh

23rd Jan 2014, 21:31

Yes the technical investigation was in depth and extremely thorough,there is no need for any of this speculation

But MoD won't publish it. This removes the opportunity to ask informed questions at the inquest. To me, this means Cornish is spot on....

I call bollocks on this, I am detecting a strong whiff of someone being scapegoated to save face of VSO, once again.

MoD have form here. They lie in court, and mislead by omission and commission. One day a Coroner will do his job and recommend charges be brought for perjury.

Q-RTF-X

23rd Jan 2014, 21:37

Excerpting from the post by Cornish and focusing on one element.

20 separate people do not miss the fundamental safety checks on seats....

Back when I learnt about seats as a humble liney I, like everybody else was taught that you are climbing on a bomb, one that wants to fire, one that wants to kill you and will do so if you do not give it 100% respect for every single second you are working near it.Looking back a zillion years ago to my days as a humble liney on Vulcans, Hunters and Frightnings I have to identify with the suggestion that "20 separate people" is a sufficiently large number to swallow. Granted there are differences in seat type, installation and generation (seats and people) but the fundamentals in training and awareness of hazards I feel pretty sure are still there, or certainly should be. Over the time I was active in line and ejection seat work I encountered a few hairy "there but for the grace of God" type personal lapses that are the inevitable consequence of requiring a human interface and such are always present but, it's the "20 separate people" bit that I find hard to swallow and should be a worrying number. Heavens above, one would have thought that at least one of those 20 would have identified that something was not quite right; another element in the mounting sequence of events perhaps ?

srobarts

23rd Jan 2014, 21:51

20 separate people
Both the Lincolnshire Echo and the BBC Look North had 7 individuals (including Sean Cunningham) entering the cockpit. The BBC also had the bit about 19 occasions. Would everyone of those 7 have been expected to check the safety of the seat?

NutLoose

23rd Jan 2014, 22:20

Yes, you would first glance at the stowage in the cockpit to ensure it was empty, then check the seat to ensure all the pins were in before entering the cockpit., it is drilled into you, they can and do kill people.

RAF Germany was slightly different as the main gun sear was not installed on the ground on the Jags, something to be honest I could never understand, because it takes seconds to fit and remove, so in that case there would be one pin in the stowage.

When strapping in you would do a final check to ensure all the pins were in the stowage then hold up 5 fingers to show all 5 pins were stowed and wait for an acknowledgement.

Many moons ago they were moving an old gate guardian off the gate to refurbish it in the USA and the seat fired killing to guy on brakes, there was a worldwide alert and all gate guards were checked, several were found to still have live seats fitted!

Easy Street

23rd Jan 2014, 23:05

I've seen a photo which recreates the condition that Sean's seat handle and pin were believed to be in when he climbed into the cockpit on that fateful day. Based on what I've seen, I woul believe it if you told me that 100 people had missed the unsafe condition. Viewed from the front of the seat, the condition is obvious, but cockpit access checks are always carried out from above, from where the condition is not obvious at all. There are subtle visual clues and I'm told these have now been widely promulgated to the user community. VSO conspiracy theories are probably wide of the mark on this occasion.

The Old Fat One

23rd Jan 2014, 23:10

I gotta confess, I'm totally bamboozled as to why anybody is seeing cover ups and conspiracy here :confused::confused::confused:

As someone who has spent all of 1 hour 30 mins on a bang seat (pax in Jaguar circa 1980) and is not an engineer, the unfolding sequence of events seems perfectly clear and the inquest testimonies completely revealing.

The coroner will deliver the verdict, which has FA to do with the RAF/MOD, and what happens after that is, at this point, conjecture. From where I'm sitting, I can't see how anything is being held back.

NutLoose

23rd Jan 2014, 23:53

Agreed, but that is a design flaw that needs correcting, no way should you be able to fit a pin with the handle out of position.

longer ron

24th Jan 2014, 01:49

But MoD won't publish it. This removes the opportunity to ask informed questions at the inquest. To me, this means Cornish is spot on....

They will publish...after the inquest is completed !

So far I have seen no desire to cover up,any important information relevant to cockpit safety has been passed on to the operators,it just has not thus far been published into the public domain!
The CAA put the shackle bolt information into the public domain very quickly after the accident !

longer ron

24th Jan 2014, 01:58

Both the Lincolnshire Echo and the BBC Look North had 7 individuals (including Sean Cunningham) entering the cockpit. The BBC also had the bit about 19 occasions.
Would everyone of those 7 have been expected to check the safety of the seat?

Yes it is the responsibility of every person entering or working in the cockpit to ensure that the relevant safety devices are fitted,one needs a competency to do so - which is renewed every 6 months.

Just This Once...

24th Jan 2014, 06:06

I'm not sure everyone is listening. The seat appeared to be safe with the pins in the correct places. I too have seen what the pin and seat pan handle looked like when set in this condition - it looked safe, but tragically it wasn't.

I have no reason to doubt that the 7 people that checked the seat (including Sean) carried out their checks diligently and believed the seat to be safe. Quite honestly if I had checked it the list would have just increased to 8. To me (and the SI) the seat has a design flaw that allows the pin to be inserted when not safe. When I flew this seat type (Hawk & Tornado) I had no idea that this was possible.

The SI did not bury this bad news - as soon as this became known to them all users of the seat were alerted with photos and instructions on what to look for. They did not wait for the conclusion of the SI or the Inquest.

dctyke

24th Jan 2014, 07:23

Seat pan handles on previous Mks of seat have been modified before when it was found that the pin could be wrongly fitted. I'd be amazed that this problem was not known to MB. As for ths Mk 10 seat shackle, I would be asking the German Airforce why they spent a lot of money completely re-designing theirs.

tucumseh

24th Jan 2014, 08:47

From Lincolnshire Echo

AVM Green said concerns over engineering manpower, a dilution of skills and training were never raised in the context that they made it dangerous to fly.

Oh for goodness sake. Not again.

That alone tells you MoD is fully embroiled in covering up. Was the Safety Case updated to reflect the above changes to the baseline?

The initial SI members, in all probability, did a very good job. But why did the MAA/MoD (same thing) withhold the report until after the inquest. Easy. MAA/MoD do not want informed questions. The Coroner should have jumped on them straight away, citing precedent.

Background Noise

24th Jan 2014, 09:01

1.3VStall

24th Jan 2014, 09:10

Tuc,

I agree wholeheartedly.

a dilution of skills and training were never raised in the context that they made it dangerous to fly - in AVM Green's own words.

In all my 28 years in the RAF if ever the question of dilution of skills and training in engineering manpower was raised, which it was many times, it was invariably in the context of a potential impact on flight safety.

Still, AVM Green managed to get in some words of management bolleaux to support his case. I'm sure the Reds groundcrew were looking forward to being "uplifted"!

airpolice

24th Jan 2014, 09:44

Martin Baker Press Release:

RAF RED ARROWS INCIDENT ON 8TH NOVEMBER 2011
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.

So, the pin can be in place while the seat is armed, but that's not a design fault?

Wrathmonk

24th Jan 2014, 09:59

Slight thread drift but a quick q for the seat experts out there - if it was the lap strap that was routed through the handle, had the sequence subsequently worked normally, would full man-seat separation have occurred? Clearly the deceleration forces of main chute deployment (which aids the man/seat sep if I recall correctly) may cause component failure but would it have been the cable between handle and seat that failed or the harness?

tucumseh

24th Jan 2014, 10:07

I think you will find that the SI report is available to the Coroner. It forms part of the evidence. The witnesses are there to expand on the evidence. It is only publication to the wider public that is withheld until the inquest is complete.

Yes, it is available to the Coroner. But not to people who would actually know what questions to ask. Please note, that in all the similar cases of attempted cover-up discussed here (Nimrod, Chinook, Tornado, C130, Sea King etc) it is members of the public, not MoD staff, who have revealed the truth.

The witnesses are required to state the truth, the whole truth and nothing but the truth. That means they are not to mislead, by omission or commission - which is on a par with perjury. In all the above cases, MoD did. You've got to admire their consistency.

tucumseh

24th Jan 2014, 10:17

design fault

Perhaps it is a design DEFECT! If it turns out to be so, they can claim they didn't lie.

airpolice

24th Jan 2014, 10:20

Tuc, you may be right. We can expect a new design to be an evolution rather than a fix.

That way they can say the design has matured into the new style rather than having needed to be fixed.

Distant Voice

24th Jan 2014, 10:52

I would like a coroner to state that in the interest of obtaining the WHOLE truth, SI reports should be placed in the public domain well in advance of the inquest; in fact well in advance of the pre-inquest hearing. In the case of the Super Puma Fatal Accident Investigation, currently taking place in Aberdeen, the AAIB published their 209 page report over two years ago. If they can do it, so can MoD/MAA.

DV

tucumseh

24th Jan 2014, 11:01

Any word of a fleet inspection of the offending assembly?

On 10th November 2005, in reply to an MP's question about trend failures (on Chinook) Adam Ingram replied that trend failures only apply to that tail number. If a similar failure is found on another aircraft, that is another, separate case and not considered part of a trend. MoD/MAA has consistently supported this statement. Routine monitoring of trend failures was cancelled by the Chief Engineer in 1991. (That timeframe again).

Assuming an inspection HAS been ordered by someone sensible, I won't hold my breath waiting for an admission Ingram was deliberately misled. But all here should be concerned that this is the level of advice given to Ministers (and courts) and an indication of how MoD will lie. And concerned that "colleagues" in MoD are prepared to lie to Ministers in order to hide "savings at the expense of safety"; and the reasons why the "savings" were thought necessary.

Distant Voice

24th Jan 2014, 11:08

The Old Fat One: Many thanks for that information, but the witness only states that the indications were that the bolt was "Vastly over-tightened". We are assuming that that means more than one and a half threads showing. But surely someone must have checked the bolt after the accident. If only one and a half turns are showing, and the bolt vastly over tightened, there is something wrong with the instruction. It has already been stated by one witness that instructions were vague.

Has there been any evidence presented to the court by the person who fitted the nut and bolt? Were approved nuts and bolts used?

DV

NutLoose

24th Jan 2014, 11:32

If you read the previous posts, sometimes a lot of torque was needed to achieve the 1.5 threads showing, not all nuts are equal in size, nor are bolts, have a bolt a fraction to short and a nut a fraction to deep and you struggle... you erm, don't just throw any nut and bolt in there and hope for the best.

I still remember the Westland Split pin holes, that must have been drilled from both sides or offset as they would line up one side, but not the other.

Mortmeister

24th Jan 2014, 11:51

Wrathmonk,
I think I would want to see exactly which strap was routed where before making a judgement on that. I am struggling to picture it in my mind.

WRT the strength of Harness v Handle Linkage question, the Harness is very strong, designed to take massive loads and it is a mechanical linkage to the Handle. It is fair to say that may well have had a significant effect on man/seat separation.

ExRAFRadar

24th Jan 2014, 12:03

a dilution of skills and training were never raised in the context that they made it dangerous to fly.

Begs the question so what context were they raised in then

Distant Voice

24th Jan 2014, 12:04

sometimes a lot of torque was needed to achieve the 1.5 threads showing, not all nuts are equal in size, nor are bolts, have a bolt a fraction to short and a nut a fraction to deep and you struggle

So whilst 1.5 threads may be ok with one type of nut and bolt it may not be with another.

I suppose my questions are simple. From the material evidence after the crash has MB confirmed that (1) the approved nut and bolt type was fitted, and (b) the specified number of threads were shown. If the answer to both questions is "Yes", then the wrong criteria is being used to determine correct fitment.

DV

jimgriff

24th Jan 2014, 12:35

A zero/zero ejection puts great demands on the 5' drogue to withdraw the main chute from the headbox. There is no momentum (speed) to provide the drag required to work at maximum efficiency. However- they do work and have done many times in zero/zero conditions. But if the scissor shackle was vastly over tightened then that is just one more difficulty for the designed sequence of events to overcome. Without the drogues being released there would be no complete man / seat separation as the main parachute cannot deploy despite the harness being released from the seat anchor points by the barometric time release unit operating.
I find it inconceivable that a pilot of his experience had wrongly routed the harness through the ejection handle.
I'm also not able to see on the Mk10b how the safety pin can be inserted and not lock the handle in its proper place- just doesn't work- if the handle is not in housing properly the pin doesn't fit.

cornish-stormrider

24th Jan 2014, 12:43

So Flt Lt Cunningham twice routed a strap thru the handle??
pull the other one,
If this is possible then it is not a design flaw, or defect it is fundamentally unsafe.

Now forgive my lack of type specific knowledge here but how different is the strap arrangement in a hawk to an F3 ? Circa 98 onwards.

Because when I had my backseat there were only two tongues that when into the QRF.

They came down over the shoulders, the crotch straps came up and thru the square ends of the lap straps then the tongues came thru the crotch straps and into the QRF.

You then tightened the laps before the shoulders and your liney adjusted the slack out behind you.

I can see a possible way that a crotch strap could be routed thru the handle but not a lap.

Regards

jimgriff

24th Jan 2014, 12:52

Cornish- That's how it's done on the Hawk too.
I cant see how a routing issue arose either.

lj101

24th Jan 2014, 14:26

Jimgriff

There are a couple of incidents from RAF Valley recently of this happening plus it happened on the Sea Harrier with an exchange officer so there's a few I'm aware of - how many live ejection seats have you strapped into?

Justanopinion

24th Jan 2014, 14:33

I find it inconceivable that a pilot of his experience had wrongly routed the harness through the ejection handle.
I'm also not able to see on the Mk10b how the safety pin can be inserted and not lock the handle in its proper place- just doesn't work- if the handle is not in housing properly the pin doesn't fit.

Jimgriff, mistakes happen irrespective of how experienced you are, indeed I think it's around 1000 hours is often quoted as the most dangerous time. I knew the chap that LJ101 mentions and the incident - he was hugely experienced. As for the pin - if it can go wrong , it will.

langleybaston

24th Jan 2014, 14:35

as a mere Metman, what is 1/2 a thread ....... I am not an engineer so .......?

dragartist

24th Jan 2014, 15:01

Langley,
I guess like me you are feet and inches man. In this context they are talking about the thread pitch or peak to peak measurement. so say we have a 1/4" diameter bolt which has a thread of say 20 threads per inch then the pitch would be 50 thousands of in inch.

to have the standard one and a half threads poking through the nut would be 75 thou. Now 62 and a half thou is one 16th of an inch.

As you can imagine there is a tollerance on all the things. In general terms we look to have a minimum of one and a half threads poking through and may accosiate this with the term "in safety"

Now in this particular case the one and half threads appears to have become presciptive. (as a measure of the tightness. This is not good)
Imagine turning the nut through another half turn to achive this presciption. this would mean moving it 25 thou and may distort the shackle.

I can do mm as well but most aircraft of our generation use engilish/american measurements.

There are one or two with a mixture. French helicopters were problematic for me. we did a number of modifications and could not get the hardware. every Enlish bolt had a label stuck besides it. with special dispensation. It is so important to get the right bits. I even had a case on the Nimrod with some Oxygen fittings that had metric screws! It could be disasterous.

Hope this helps

I am sure you are a good met man.

tucumseh

24th Jan 2014, 15:23

I still remember the Westland Split pin holes, that must have been drilled from both sides or offset as they would line up one side, but not the other.

Almost as bad as Boeing not drilling the holes in the first place. The key question, however, is were MoD content with your example? They were on Chinook. :ugh:

Then it happened again.......

dragartist

French helicopters were problematic for me.

I remain convinced that is where the RAF Chief Engineer got his idea from to stop maintaining configuration control.

I recall, 40 years ago, an Admiral being impressed with my French as I was apparently repairing a Gazelle clutch with my sole reference being a French drawing. We kept the translation in a drawer. At least we had an audit trail to our standard of clutch, unlike the Argie Chinook pubs used by the RAF.

Excellent summary of Imperial threads. My memory tells me there is a Def Stan on your labels, especially a warning of Unified threads. I'd still want to know if the nut in this case had been re-used, as that is a common reason for over-tightening. If such questions had been asked I'm sure the local journalist would have twigged its importance. What we're reading at the moment is a series of unchallenged and increasingly ludicrous MoD statements.

NutLoose

24th Jan 2014, 15:29

http://www.portlandbolt.com/faqs/wp-content/two-threads-nut.gif

Hamish 123

24th Jan 2014, 16:02

I was somewhat surprised (to say the least) to read in The Telegraph today that " a military investigation . . . had earlier concluded that the way pilots were selected for [the Red Arrows] could also have been a factor . . . the choice of pilots was 'heavily weighted' to how they would fit into the team rather than flying ability".

So, in summary, some Red Arrows pilots are not quite top notch, therefor increasing the likelihood if an accident happening with an ejector seat.

That's surely got to be the biggest load of bollox, no? Why would "a military investigation" come to such a ridiculous conclusion?

I'm staggered. What am I missing?

Growbag

24th Jan 2014, 16:11

If it is identified that a lot of rules and regulations are contravened, then a military investigation may choose to ask why noone has either picked the contraventions up, or why noone (within the group of people) felt they should speak up to change the culture. If the group of people are self-selected (i.e. people who would fit in) then it is unlikely that they would even identify the issue, or be likely to raise them.

Seems perfectly understandable to question how things are done when they are so different to the rest of the military selection processes...reading the Telegraph article.

goudie

24th Jan 2014, 16:19

the choice of pilots was 'heavily weighted' to how they would fit into the team rather than flying ability".

From my re-call of the tv programme, on this subject, didn't they have to have the right flying abilities first, then final selection was made by the current members re. 'fitting in'?

just another jocky

24th Jan 2014, 16:43

I believe the minimum standard is "above average", which when you are talking about such a small group of highly trained professionals to select from in the first place, means the article does appear to be a bit.....well......:mad:

dragartist

24th Jan 2014, 17:10

Good picture Nutty, I wish I was clever enough to insert graphics (or extracts from my Dads 1950s trade training notes!) Now then is that one or two threads poking though? I rest my case M'laud.

Tuc, yes three Olympic type rings (I'd be guessing at Def Stan 05-40 I could probably have written chapter 400 of 00-970!) now there was no standard for identifying metric threads on English aircraft so they were labelled "Metric" This was in the extreme only where proprietary items had to be used.

I was dead worried about the unified fixings on the Gazelle as some were blind threaded holes in potted inserts into the nomex honeycomb structures. There may have been a couple on the Lynx and Puma as well.

Now you will know the Nimrod had mostly BA/BSF on the airframe, all our racks were unified. the later avionics were Metric post about 1980. can't remember if the Starwindow stuff from America was metric. I would probably have had discussions on the topic. the problem was metric hardware to aircraft standard with metallic locking elements was as rare as rocking horse droppings back then. Getting hold of stuff from the Jaguar, Tonka or even Sea Eagle Missile was an issue.

I certainly remember the Argentine CH47 at Wroughton. I thought it only got used for BDR training. We had the pylon at JATE for a spell when we were devising transport dollies. I wonder how they went on with the A109s

Apologies for the tread drift. just expanding on a few points and illustrating scope for Mr Murphy coming home to roost.

Wander00

24th Jan 2014, 18:19

I always understood that golfing ability was a key factor, which is why I never applied. OK, I'll get my coat......................

Easy Street

24th Jan 2014, 18:59

On the selection issue, the irony is that Sean's intake year was more "diverse" than preceding years because it was the first for a while that wasn't dominated by ex-creamie QFIs of a particular vintage. It even included 2 GR4 pilots! The suggestion of cliqueyness in selection over the preceding period is particularly uncomfortable reading because both the Crete and Bournemouth accidents can be cast in the light of 'risky shift' in a closed-shop elite. I wonder how much significance will be attached to the fact that Red 1 for the period in question had been promoted directly from the team and had not spent time away as per the current incumbent.

It saddens me that the display flying world is still battling these issues many years on from Kemble, Ramstein, Fairchild, Elmendorf... one would have thought that enough case studies existed by now :sad:

Easy Street

24th Jan 2014, 19:39

On the MB 'no design fault' notice, you need to read it with lawyerly attention to detail (my bold):

satisfied that neither a mechanical nor a design fault were to blame for the fatality

They are not denying that a design fault (eg in the handle or safety pin) might have caused the ejection. However, since the ejection should have been survivable, the fatality was due to the failure of the parachute to deploy. As soon as the over-tightened bolt was discovered, therefore, MB could issue that statement to reassure their customers without needing to establish why the ejection had happened in the first place.

Now, one for the accident investigators among you. A service inquiry is required for major injuries. If Sean's parachute had deployed, it is still quite possible that he would have broken a few bones and precipitated an SI. The cause of that accident would be the pulling of the seat handle, with its unsafe condition as a contributory factor. Given that the outcome was worse, ie fatal, does that make the over-tightening of the shackle bolt an aggravating factor to the same root causes? Or is the over-tightening of the shackle bolt now the cause of the accident, with the unsafe condition of the handle and its pulling as contributory factors? And would the distinction have any significance for liability or culpability?

Flight_Idle

24th Jan 2014, 20:33

Excuse me for butting in again, I'm just wondering about the workings of the modern ejector seats. How far does the seat pan handle have to move before firing the seat?

From my non specialist point of view, it would seem sensible to have a movement of an inch or so, which would make it quite obvious to those entering the cockpit, rather than a 'Hair trigger' type of thing.

I'm as baffled as anyone else, yet have over 35 years of 'Hands on' aircraft experience.

Easy Street

24th Jan 2014, 21:13

The pull is of the order of an inch (a little more if anything) and about 30-40lb force. The issue appears to be that the handle had been inadvertently pulled most of the way through some as-yet unstated means on the previous sortie, leaving it on something close to a hair trigger.

lj101

24th Jan 2014, 21:54

does that make the over-tightening of the shackle bolt an aggravating factor to the same root causes? No

Or is the over-tightening of the shackle bolt now the cause of the accident No

unsafe condition of the handle and its pulling as contributory factors Yes

And would the distinction have any significance for liability or culpability?

If a company were aware that over tightening of said shackle bolt in a zero zero ejection may result in the failure of their seat - in my opinion they are NOT culpable but they are liable.

Just my irrelevant views as I'm not a SME.

Lima Juliet

24th Jan 2014, 22:16

Excuse me for butting in again, I'm just wondering about the workings of the modern ejector seats. How far does the seat pan handle have to move before firing the seat?

I know someone who was sitting on a Mk10 seat similar to this in a Tornado when they had a hydraulic failure that meant taking the over-run cable (as they were too heavy to take the threshold cable). On touchdown he said to himself that if they didn't take the cable that he would punch them out as otherwise they would have a seriously bumpy ride through the rocks of the desert beyond the end of the runway. As he watched the arrestor gear go past him on either side of the runway with no feeling of retardation he reached down and pulled the ejection handle that left it's housing in the seat - at the same time the hook and cable started doing their job of bringing the jet to an abrupt halt and forcing the handle back into the seat housing! He now didn't know if the seat was going to fire or not and had to go through some very thorough checks with the safety pins/command eject lever to try and ensure it didn't subsequently go off. The hardest choice was opening the canopy because if the seat went off at this point before the armourer had done more checks and put more safety interlocks in place then the guy on the seat would most certainly collect the canopy after a very short 25g acceleration.

So in short - you do have to pull the bang seat handle pretty hard on the Mk 10 seats...

LJ

SirPeterHardingsLovechild

24th Jan 2014, 22:47

I'm still a little amazed that a seat pan handle could be half pulled and the pin fitted.

My tuppence worth is that when you check seat pins you are mostly doing it for your own safety, not then next person's.

Moving seat pins is a different matter, and judging by the BOI Presidents comments, it was Flt Lt Cunningham himself who fitted that pin incorrectly, 4 days previously.

4 days? November? Was this aircraft towed in and out of the hangar with a techie sat in the seat on brakes !

I note a previous posters comment that he had seen a photo of an unsafe seat pan handle and says it is possible, but I am stunned.

Surely an A/F, B/F, T/R on a Hawk would pick this up?

And finally, the last person to check that pin...

NutLoose

24th Jan 2014, 23:02

They are not denying that a design fault (eg in the handle or safety pin) might have caused the ejection. However, since the ejection should have been survivable, the fatality was due to the failure of the parachute to deploy. As soon as the over-tightened bolt was discovered, therefore, MB could issue that statement to reassure their customers without needing to establish why the ejection had happened in the first place.

Well to a Layman, that reads as two design faults, one allowing the pin to be incorrectly fitted and one allowing the shackle to be incorrectly torqued, if it isn't a design fault then why are the RAF / MB looking to replace the bolt with a shouldered bolt to correct the issue, as a rewriting of the maintenance procedure would rectify it.

Sphlc read 134

SirPeterHardingsLovechild

24th Jan 2014, 23:41

Thanks for the steer, I'll wait for the photos.

I was stood next to the Canberra T17 when the armourer Ted T****r(?) fired the seat in the hangar at Wyton in the early 80's. And stood in the bomb bay when the electrician J**n L****t fired the canopy dets. Maybe that's why I'm deaf.

Both incidents had about 4 bits of swiss cheese lining up.

But this must be a world record. Murphy's Law must come into effect after 10 bits of cheese, and this is more than 20 !

Mortmeister

25th Jan 2014, 10:59

Easy Street is about right with the length and pull required to initiate ejection. Having pulled these handles on many occasions, it is pretty obvious when it is out. Sorry all, but I'm struggling with how this scenario can have been allowed to develop!

The seat pins should have been moved to 'Safe for Maintenance' position and signed/countersigned by the armourers prior to being towed into the hangar after the previous flight. Although the Seat Pan Pin had been fitted by the pilot, the armoured concerned is required to check the correct fitment of that plus the MDC Firing Handle and the MDC Firing Unit Pins (all fitted by the pilot) in each cockpit.
4 days later when towed out, they should have been placed 'Safe for Parking,' again requiring a check of all pins as well as removing the Main Gun, Rocket Initiator and Manual Separation Firing Unit Pins. What happened during the time in the shed the BOI should know from aircraft paperwork.

I have to ask myself, were the armourers adequately manned, trained and experienced or were they overstretched?

SirPeterHardingsLovechild

25th Jan 2014, 11:09

Just to add

4th November 2011 was a Friday
8th November 2011 was a Tuesday

Just in case me and Mortmeister have made an assumption. I don't think the aircraft are left out overnight, let alone over the weekend.

Edit: In November, out of the display season

langleybaston

25th Jan 2014, 13:27

Thank you people for the explanation of the 1 1/2 thread matter ...... it seems extraordinary to a layman that something so vital should need judgement.

It was precisely to obviate "judgement" that the Met Office ceased using mercury barometers and went to precision aneroid versions: there was a number value to read, not a judgement to make.

On reading the value and logging it, the observer was required to calculate the difference from the previous reading as a first check, and see how the series was developing. Before passing the calculated various QFF QFE QNH values he was required to obtain the forecaster's initials. The forecaster kept a separate check board. On passing the values to ATC the observer was required to obtain ATC initials.

The aneroid itself was required to pass comparison checks with a travelling master instrument, which was itself recalibrated at Bracknell on a routine basis.

I offer the above as an illustration of how we went about safety by designing- out error to the nth degree.

dragartist

25th Jan 2014, 13:49

Langley,
I think Mort sums up all the checks and balances that should have been in place at #180 quite nicely. just the same as your example of getting the altitude spot on. Air safety is a team effort and goes all the way back to the guy on the drawing board and everything in between. What we do need is total disclosure and honesty so we can all learn from each other and prevent the tragic occurrences like this.

NutLoose

25th Jan 2014, 13:58

The seat pins should have been moved to 'Safe for Maintenance' position and signed/countersigned by the armourers prior to being towed into the hangar after the previous flight. Although the Seat Pan Pin had been fitted by the pilot, the armourer concerned is required to check the correct fitment of that plus the MDC Firing Handle and the MDC Firing Unit Pins (all fitted by the pilot) in each cockpit.
4 days later when towed out, they should have been placed 'Safe for Parking,' again requiring a check of all pins as well as removing the Main Gun, Rocket Initiator and Manual Separation Firing Unit Pins. What happened during the time in the shed the BOI should know from aircraft paperwork.

Is that how it is done now? There were no differences between maintenance and parking during my service, all 5 pins would be in UK wise, or 4 RAFG wise, (jag) though I cannot remember if the 5th pin was fitted for maintenance, the pins were just checked by whoever was operating as a Liney, be it a Flem or single trade, they were trained to check / inspect the seats.
The armourers didn't do them on AF/BF or turn rounds unless they to were operating as a Liney and as such would cover as one person would do, the whole jet. From checking the engines, airframe, electrics, NAVWASS, through to refuelling, oils and gasses such as seat oxy etc, the armourers simply rearmed / rerolled them and cleaned the guns or seat removal and fit.

VictorNavrad

25th Jan 2014, 14:25

The seat pins should have been moved to 'Safe for Maintenance' position and signed/countersigned by the armourers prior to being towed into the hangar after the previous flight. Although the Seat Pan Pin had been fitted by the pilot, the armourer concerned is required to check the correct fitment of that plus the MDC Firing Handle and the MDC Firing Unit Pins (all fitted by the pilot) in each cockpit.
4 days later when towed out, they should have been placed 'Safe for Parking,' again requiring a check of all pins as well as removing the Main Gun, Rocket Initiator and Manual Separation Firing Unit Pins. What happened during the time in the shed the BOI should know from aircraft paperwork.
+++++++++++++++++++++++++++++++++++++++++++++++++
Was the earlier incorrect routing of strap through the seat handle and possible movement of the handle from its normal position formally recorded during post flight debrief as needing checking by armourer or seat specialist. Also is there any visible reference mark that makes it clear that the handle is correctly located. Can't understand why MB would design a handle where pin can be inserted when handle not fully seated.

raytofclimb

25th Jan 2014, 14:48

To clarify for the benefit of Sirpeterhardingslovechild in post #177, if the handle is displaced from its housing with the seat pan pin out, the pin will not go back in the correct hole. End of.

Assuming the handle was only 'soft pulled' to the first detent and hadn't fired, which has happened several times between three types I've flown in my career, it can be re-seated, not without losing a few heartbeats, and the pin reseated correctly. Drama over. Rare but documented.

However, this small displacement opens a gap between the handle base and its housing which the pin can be (and has been) pushed into. In this case, the handle is still at the first detent, cannot be reseated and is liable to fire the seat with a further upward pull of sufficient force.

If the seat occupant was to relocate the pin, by feel into the gap they would be none the wiser. The error could only be seen by adjusting the QRF/paunch/fat thighs and looking vertically down to check the pin was centrally located in the handle. I always checked by sight before unstrapping, particularly after seeing pictures, pre-dating the incident in question.

Anyone looking in or down, checking that the pin is fitted, particularly with parallax from peering into the cockpit, could see the pin's handle and assume that it was safe if they didn't look to see that the handle was housed and the pin CENTRALLY LOCATED AND FULLY HOME.

I hope this clarifies for those who have a little bit of (dangerous) knowledge. I find the level of amateur speculation here appalling. This incident was close to me on several fronts.

Ray.

Easy Street

25th Jan 2014, 14:57

Interesting...

To clarify for the benefit of Sirpeterhardingslovechild in post #177, if the handle is displaced from its housing with the seat pan pin out, the pin will not go back in the correct hole. End of.
Which 'correct hole'? The correct hole in the handle, or the correct hole in the collar around the handle?
I hope this clarifies for those who have a little bit of (dangerous) knowledge. I find the level of amateur speculation here appalling.

I think all you did was muddy the water there with a bit of speculation. Sean's pin was in the correct hole on the handle, not in a gap between handle and seat. However because the handle had been pulled upwards the hole in the handle was above the level of the collar so there was nothing preventing the final pull.

cornish-stormrider

25th Jan 2014, 19:32

which is a design fault - if the handle is not fully home there should be zero way for the pin to be fitted back into the correct hole.

and I still dont buy the bit about being able to "not notice" you have routed a big black and yellow scary handle thru the straps.

if it is possible then lets see pics on a deactivated trg seat or one with the carts removed to demonstrate how this is all Flt Lt Cunningham's fault.
WHICH I DO NOT BELIEVE FOR ONE SECOND.

there is far more to this than a simple chain of operator errors.

Flight_Idle

25th Jan 2014, 19:54

Ref post 186...

Assuming the handle was only 'soft pulled' to the first detent and hadn't fired, which has happened several times between three types I've flown in my career, it can be re-seated, not without losing a few heartbeats, and the pin reseated correctly. Drama over. Rare but documented.

Just for clarification, I assume the seat would have to be thoroughly checked by the relevant specialists first after being 'Soft pulled', so not just the 'Drama over' as it came across to me.

I probably mistook your meaning, but a pilot, or any other 'Non seat specialist' re-seating a moved handle would be mad in my opinion.

Engineers are curious people & do think 'Cross trade' it's in our nature, just asking questions, not really giving opinions.

Easy Street

25th Jan 2014, 20:28

to demonstrate how this is all Flt Lt Cunningham's fault.
WHICH I DO NOT BELIEVE FOR ONE SECOND.

I don't think anyone is insinuating anything of the kind - not least because he had nothing to do with the over-tightened bolt. As others have said, the inquest evidence to date has made it plain that there were a lot of people (yes, including Sean) involved in the chain of events leading to the accident. I haven't seen anyone attempting to pin blame, apart from a few half-hearted attempts to start a conspiracy theory!

cornish-stormrider

26th Jan 2014, 04:01

so the insinuation it is all the fault of the pilot strapping in incorrectly twice is the root cause has passed you by?

now if I remember correctly and it is o' stupid o clock and i need coffee so i stand proud to be corrected by any plumbers, the handle pulls on a trapezium type shaped release that when fully removed allows the spring inside to expand forcing the firing pin into the cart starting off the process.

said handle requires a fairly hefty chunk of force 30-40lb, IIRC, to pull.

Now, you try picking up a strap, feeding it thru a black and yellow handle and connecting it up as per my previous post AND THEN TIGHTENING THE STRAPS TO PUT 30-40lb of into the handle to move it even to the first detent. ( something I don't recall)

it does not matter which strap, the crotch, the lap, the neg G and QRF or the shoulder.

it does not strike me as unnoticable - now, those of you fortunate enough to have had a seat incident and be here to recount it, when you realised you might have made a cock up and needed the assistance of an armourer can i assume that you made damn sure you went nowhere near the handle or did anything to upset a mechanism while waiting and saying a lot of prayers?

let us say, for example you realised the handle was part pulled - for whatever reason......

what are you going to do...?

now onto this other bit - the part about the handle being part pulled and the pin put back incorrectly, park the bit that it won't go thru the hole as it does not line up and so therefore must be put between the handle base and the top of the housing???

yeah, i'm having trouble buying this too and then a chain of 19 (as reported) people all fail to notice the pin does not look right.
Are they ALL so blase about seat safety that they cannot see a pin is not in the correct place.

19 separate entries into that cockpit, plus the entry of Flt Lt Cunningham on that sad day........?

ALL missed it....

I dont think so.

dervish

26th Jan 2014, 06:38

NigelOnDraft

26th Jan 2014, 08:14

I think its disgusting that these insinuations are made in court. Is it an MoD thing, or an RAF thing? Seems to me it happens at almost every RAF inquest and seldom at others. If it turns out the Board of Inquiry had already determined the pilot was not to blame, then whoever made these insinuations should be put in a hole. If one takes your viewpoint to it's logical conclusion, then there is no need for an inquest, and the MoD/RAF BoI/SI is taken as the complete truth, including for liability purposes.

I would counter with:
The Mull Chinook accident showed that MoD BoI/SI system is not necessarily the whole story ;)
An Aircraft Accident investigation is generally to learn from / prevent future occurrences, and not to allocate blame.
I do not know exactly the (defined) purpose of an inquest, but I am pretty sure it is not as the item above.It is stated the coroner has the MoD SI report in front of him, and that it will be released at the end of the month (?). I think we probably need to wait until the coroner has concluded, and the SI released.

Meanwhile, I think to those on the outside, we are just seeing a complex legal process occurring with conflicting information / apparent purpose confusing to the layman.

NoD

SirPeterHardingsLovechild

26th Jan 2014, 09:30

raytofclimb

To clarify for the benefit of Sirpeterhardingslovechild in post #177, if the handle is displaced from its housing with the seat pan pin out, the pin will not go back in the correct hole. End of.

I hope this clarifies for those who have a little bit of (dangerous) knowledge. I find the level of amateur speculation here appalling. This incident was close to me on several fronts.

cornish-stormrider

to demonstrate how this is all Flt Lt Cunningham's fault.
WHICH I DO NOT BELIEVE FOR ONE SECOND.

Don't think anyone said "all Flt Lt Cunningham's fault"

If any of those comments are directed at me, I'm happy to stick my neck out and state that he was at least partly responsible.

Possibly, further down the line, lawyers will put a percentage on this and its called "contributory negligence"

Easy Street

26th Jan 2014, 09:34

Now, you try picking up a strap, feeding it thru a black and yellow handle and connecting it up as per my previous post AND THEN TIGHTENING THE STRAPS TO PUT 30-40lb of into the handle to move it even to the first detent.

I know of at least 2 occasions on which a lap strap has been incorrectly routed through the handle of a Mk10 seat when strapping in. One by a colleague under pressure on a course, and another by a friend scrambling for an op sortie. Both were rushing and both realised what they had done in their final pre-take off checks; neither had moved the handle at all so they were able to put the pin back in and adjust the straps. It's worth noting that the pull required on the handle is halved due to the mechanical advantage offered by the strap, and 15-20 lb is well within a realistic range for a lap strap pull - especially if you are making them extra tight for some aerobatics practice...

Feeding into such an occurrence could be groundcrew dilution (ie why didn't the liney spot the strap error?), unit culture/SOPs (were they imposing unnecessary time pressure?), safety process (awareness of previous close calls) and seat design issues. The practice of unstrapping during taxy back (during which the pilot tends not to look down, replacing the pin and undoing straps by feel) would also remove the opportunity for others to spot the condition.

so the insinuation it is all the fault of the pilot strapping in incorrectly twice is the root cause has passed you by?

I haven't seen anyone say it is ALL HIS FAULT. It looks likely that there will be several causal factors, and it is inconceivable that Sean would have had the opportunity to influence more than one or two. You also missed my comment that the pin was in the correct hole in the handle, not in a gap.

dervish

26th Jan 2014, 09:52

Nigel, you quoted my post but then listed points as if I'd argued against them.

The Inquest (in England) is meant to be non-adverserial but MoD (RAF) always seem keen to introduce unfounded accusations to divert attention from the main issues and are very good at persuading inquiries that certain witnesses shouldn't be called or facts revealed. Just an observation based on fact, including the Mull of Kintyre accident you mentioned.

awblain

26th Jan 2014, 10:17

Nigel,

I believe that the purpose of an inquest is solely to determine the cause of a death. In Scotland the rather more descriptive "fatal accident enquiry" fills the same role.

There may be a secondary opportunity to advise on lessons for the future and to spot trends to similar incidents in the past, but that's not the prime concern. I'd say an inquest is much closer in goals to a board of inquiry/accident investigation than to a trial, but the inquest is more narrowly focussed on the death, rather than building up a whole picture of an accident.

There's a lot of flexibility in the approach the coroner takes to consider wider issues. In a complex case like this, the coroner will be seeking to decide whether there is sufficient evidence to rule it was an "unlawful killing" or an "accident", or if the cause remains "open".

If it's "unlawful killing", then some sort of police investigation would be expected. It's also possible for an inquest to come to different conclusions from an inquiry, perhaps consistently, because of its different emphasis.

Easy Street

26th Jan 2014, 10:29

It's also possible for an inquest to come to different conclusions from an inquiry, perhaps consistently, because of its different emphasis

This is interesting and perhaps pertinent in this case? Might the inquest find that the sole cause of the fatality was the failure of the chute to deploy, while the inquiry finds additional causes of the accident including the (survivable in normal circumstances) pulling of the handle?

clicker

26th Jan 2014, 10:48

I have a query regarding the seats in general as I'm not technically minded regarding such matters.

If the seats are fitted with five safety pins and the one in the seat pan was incorrectly fitted, regardless of how, why did the other pins insertion not stop the firing sequence? Is not the removal of the pins the last sequence before engine start as another safety check?

I always thought the idea of the pins was like a weapons safety catch in simple terms in equals no go, out means go out.

longer ron

26th Jan 2014, 10:58

Just to clear up a couple of points.

It is very possible to fit the seat pan pin into the seat housing with the handle displaced,this has happened before on a different aircraft type within the last 12 years.
As others have said - straps / neg g straps have been wrongly routed within the last 5 years on hawk aircraft during strap in !

Finally to help deflect the conspiracy theory - I would just like to say that except for during seat maintenance (ie deeper than line maintenance) the ONLY person who touches the seat pan pin is the pilot/aircrew occupying the seat...NOBODY else would dare touch the pin - it is absolutely drilled into all groundcrew that we do not touch the seat pan pin...and there is absolutely no need for us to touch that pin !

Also to say that at some units - if the aircraft is serviceable and will be flying
the next day or pretty soon - the seat pins are not moved from pins park to pins serv/maint !I am not saying that the reds do this but some units do !

awblain

26th Jan 2014, 10:59

Easy Street,

That sort of thing is a possibility. In a complex case, the Coroner can also give a "narrative verdict" that allows them to describe their reasoning and the factors involved in more detail.

Generally, I'd expect a board of inquiry to take a broader view than a coroner.

However, it's hard to see how the Coroner wouldn't be interested in the circumstances of the seat firing, as that's an undeviated part of the same chain of events. The coroner took evidence about the seemingly much less relevant Night Nurse bottle, in case that was also part of the chain of events.

I think this is a particularly complex case for the Coroner to decide. Even if the Inquest were to decide that there was evidence that the seat had been fired deliberately, a firer would have expected the parachute to deploy, and for Flt Lt Cunningham to survive, and so it might be hard to assign several of the verdicts available.

Dervish,

If interested parties are stirring the pot, I would expect the Coroner to be clear in his/her verdict, and not to be influenced. Where there is secret and arcane evidence, it's certainly possible that the Coroner would not know about a whole raft of relevant circumstances, but in this case, there don't seem to be any obvious hidden factors. While the inquest is non-adversarial, in that the Coroner questions witnesses, and there is no cross examination, there are still often going to be profoundly different views amongst the interested parties.

longer ron

26th Jan 2014, 11:06

f the seats are fitted with five safety pins and the one in the seat pan was incorrectly fitted, regardless of how, why did the other pins insertion not stop the firing sequence? Is not the removal of the pins the last sequence before engine start as another safety check?

At that stage of the proceedings (ie after engine start) all the pins were already removed and therefore the seat was completely 'Live' - on the hawk - the last 2 pins (seat pan handle and canopy internal mdc pin) are removed and stowed immediately prior to engine start - all other pins are removed before strap in !

NigelOnDraft

26th Jan 2014, 11:14

If the seats are fitted with five safety pins and the one in the seat pan was incorrectly fitted, regardless of how, why did the other pins insertion not stop the firing sequence? Is not the removal of the pins the last sequence before engine start as another safety check?Of the various Pins, in a Mk10 seat only 2 are concerned with preventing the seat firing (IIRC - not flown a Mk10+ since 94, but many recent hours on a Mk4):
Seat Pan firing
Main Gun sear
Seat Pan firing is in place "Safe for Parking" which is how aircrew would expect to find and leave the seat.

Main Gun sear is removed "Safe for Parking" but inserted "Safe for Servicing". As posts above state, "Safe for Servicing" may or may not apply to routine night in/out hanger movements depending on policy.

I do not recall exactly from my service days, but on live seats now I am still frequently surprised by arriving at a cockpit, and finding the seat pin not visible, and/or straps over even through the handle. I was taught that you leave the seat as the next person needs to find it - and the 1st thing they will do is check the pin is in, so ensure it is visible without needing to get close to it. And of course, the last thing you do as you leave is check the pin isn't it...

NoD

Distant Voice

26th Jan 2014, 12:19

Generally, I'd expect a board of inquiry to take a broader view than a coroner.

While the inquest is non-adversarial, in that the Coroner questions witnesses, and there is no cross examination, there are still often going to be profoundly different views amongst the interested parties.

Awblain; Clearly, you were not at the Nimrod inquest. Andrew Walker (Coroner) exposed the limitations of the BOI, and effectively overturned the findings with regards to fuel source. Evidence was given on oath, all interested parties were legally represented, and there was cross examination. In this case the BOI report was placed in the public domain some six months before the inquest.

DV

clicker

26th Jan 2014, 12:33

Thanks NigelOnDraft and longer ron for your update.

awblain

26th Jan 2014, 13:49

Distant Voice,

You're right. Taking a broader view might not be the same as taking a deep enough view.

The Coroner may indeed produce a better report than an enquiry, and can set a broad scope for the Inquest. However, they can also choose to focus on a very narrow question of the cause of death.

I'd still suggest that the Inquest process is rather different from other legal hearings though - the Coroner interrogates, and interested parties' questions are permitted by the Coroner. Questioning that seems to be "cross-examination" would only be permitted if it serves the Coroner's aims for the process; the Coroner may reasonably allow the next-of-kin, and their representatives, to be more general and probing in their questions. All written evidence and evidence given in person is still under oath; witnesses can decline to answer for fear of self-incrimination.

I just wanted to highlight some of the unusual features of the Inquest process that can account for it leading to rather different results than trials or other enquiries. As to which leads to the best picture of events: it depends on who conducts them and how.

tucumseh

26th Jan 2014, 16:44

it depends on who conducts them and how

Very true. In the Nimrod case, Mr Walker was firm but fair. He did not appreciate being lied to by MoD and allowed the families a certain leeway, such as producing the airworthiness regulations that MoD told him were "irrelevant". The Government response was to try to gag Coroners.

At the opposite end of the spectrum, at the Sea King ASaC inquest (Jan 2007) Sir Richard Curtis flatly refused to allow the father of one deceased airman to challenge blatant lies by MoD. In fact, all but shouted down the father in court. The MoD legal guy didn't even have to try, it was so obvious whose side the Coroner was on. It was HE who was adverserial!

airsound

28th Jan 2014, 18:14

In case there's anyone who doesn't know, the Coroner will give his findings tomorrow, Wednesday, starting at 1000.

The MAA will not release its SI report (Service Inquiry, used to be a BoI) until sometime next week.

airsound

jayteeto

28th Jan 2014, 18:42

I spent 2 hours in the dock with Mr Walker questioning me. Firm but fair would be a good description. I left the court with the impression that he only wanted the truth, no agendas

airpolice

28th Jan 2014, 19:03

I've only ever been strapped into three bang seats, and they were all the same, and the last time was in 1975. That seat needed 80 knots forward speed to work at ground level. Nowadays I can't afford to fly anything with a proper bang seat, although a recent offer relating to a JP5 was very tempting.

No pins to check, but (IIRC) fifteen things to look for before sitting down; 5 reds, 5 blacks and 5 greens.

Then, if all looks good, check, again, the last red, and sit down. Strap in, taxy, and when ready for the off, reach up with right arm and move the red golf ball that is pressing against your neck, to a point over your right shoulder where you can see it.

On landing, make the seat safe by pulling the golfball ball back to where it presses against your neck, reminding you that seat is not going to fire.

Clearly visible by the Caravan controller as well as the Lineys and other members of the formation, everyone knew if your seat was armed.

Why did that never catch on?

Distant Voice

28th Jan 2014, 21:03

I spent 2 hours in the dock with Mr Walker questioning me. Firm but fair would be a good description. I left the court with the impression that he only wanted the truth, no agendas

And that his why he wasn't MoD's favourite coroner.

DV

BEagle

28th Jan 2014, 21:30

airpolice wrote:No pins to check, but (IIRC) fifteen things to look for before sitting down; 5 reds, 5 blacks and 5 greens.

That was the Folland seat in the Gnat. So simple and so safe....:cool:

I think that the aircraft I flew which had the most pins was the Buccaneer - clearly it was essential to ensure that they were all in the correct position pre-start and also before exiting the aircraft.

On one occasion, I don't know why, but after I'd checked my cockpit, something made me go back and check the rear seat after the navigator had climbed out. Wherupon I found that he'd transposed 2 pins into the wrong locations, meaning that one element of the seat wasn't safe as one pin was longer than the other and wasn't doing its job, being in the wrong hole.

So I relocated them into their correct locations, then joined my navigator in the line hut. True to form, being a 237 OCU staff navigator, the first thing he said was "Where the f*** have you been?". When I told him, he said "Rubbish - and how dare you stick your nose in my cockpit"......:rolleyes:

Typical of the sort of treatment we students had to put up with in those days.....:\

srobarts

29th Jan 2014, 08:45

Lincolnshire Echo tweeting live from the inquest today: https://twitter.com/adriancurtis_LE

Wrathmonk

29th Jan 2014, 09:36

Typical of the sort of treatment we students had to put up with in those days

So sometimes 'the good old days', and at a time we had 'a proper air force', weren't quite so good....;)

bakerpictures

29th Jan 2014, 09:56

Live tweets also from the Telegraph's Defence Correspondent: @martingslack

Alber Ratman

29th Jan 2014, 11:17

Martin Baker not coming out of this in a good light..

just another jocky

29th Jan 2014, 11:20

Link to BBC News website coverage (http://www.bbc.co.uk/news/uk-england-lincolnshire-25943211).

NutLoose

29th Jan 2014, 11:21

Yep agree, not painting MB in a good light, I am so glad that the armourers now know it was not their fault, I should imagine that is a great weight lifted off their shoulders.

Such a tragedy, but one hopes lessons are learnt from this so it never happens again.

NickB

29th Jan 2014, 11:26

RNAS Yeovilton Air Day. 1975. Harrier display pilot.

Didn't the bang seat go off as the display pilot was exiting his aircraft opposite the ATC tower? Poor chap didn't stand a chance.

Presumably this was investigated, but what were the findings?

Apologies for thread drift...

teeteringhead

29th Jan 2014, 11:29

I spent 2 hours in the dock Witness stand I hope jaytee, rather than dock.

But with a Geordie cum adoptive Scouser, who knows??? ;)

27mm

29th Jan 2014, 11:44

NickB,

IIRC, he omitted to insert his seat firing handle pin and stood on the handle as he was climbing out of the cockpit.

Chugalug2

29th Jan 2014, 11:51

BBC News:-
The inquest heard Martin-Baker warned some air forces but did not warn the MoD, and Mr Fisher said there was "no logic" to this.
So what is he saying, that Martin-Baker acted in an illogical way, or that the account of who received the warnings is illogical?

NutLoose

29th Jan 2014, 11:54

If they were sending a signal out to all users, would it not be the simple omission of the RAF off the mailing list that caused this? I would assume it would go out to everyone at once, and might not have been picked up at the time.

.

NickB

29th Jan 2014, 11:58

Ah I see - thanks 27mm.

ExAscoteer

29th Jan 2014, 11:59

It's not the first time a manufacturer has sent out maintenance critical information but has neglected to send it to the RAF.

Blacksheep

29th Jan 2014, 12:31

4 days? November? Was this aircraft towed in and out of the hangar with a techie sat in the seat on brakes !The seat pins should have been moved to 'Safe for Maintenance' position and signed/countersigned by the armourers . . . 4 days later when towed out, they should have been placed 'Safe for Parking . . . "Should have" - oh those awful hindsight words. "I should have" " He should have" In the end it's always the same.

I/he/she/it didn't. :(

During my time in the Royal Air Force I always, always, always checked the seat pins carefully before getting into the seat. One day I was lying on my back under a Vulcan instrument panel working on a pitot-static fault. My legs were resting on the seat and my tool roll was on the seat between my knees. I was reaching for a spanner when I noticed that the seat pan handle safety pin wasn't there. It wasn't on the floor near me, so I hadn't dislodged it when I worked my way in there. A while later someone came along and I asked them to put the pin in and yes, there it was, stuck in the stowage on the bulkhead behind the seat.

Complacency is something that creeps up on you and complacency is the root cause of so many accidents. :sad:

I learned about Maintenance from that . . .

Alber Ratman

29th Jan 2014, 12:58

All an Armourer would have done to make a seat safe for Maintenance would be to fit the main gun sear. True, it is good practice to have checked the other pins as a matter of course. The aircrew are the only people that move the firing handle pin from flight stowage to safe for parking and vice versa during the normal day (unless they are instructing an armourer to do so). It is their responsibility to check they are fitted correctly too. I know the Mk 9 seat had a similar issue with the firing handle and was always mentioned on the AAES 6 monther. However this design issue and errors/lapses made by everyone involved would not have ended in tragic circumstances if another known design fault had been tackled or mentioned by MB years ago. That is the biggest failure IMHO.

The MoD report will put the meat on the inquest bones.

Background Noise

29th Jan 2014, 13:45

The 4 days included a weekend so not so many movements as perhaps inferred.

There was no generic requirement to make the seats safe for maintenance just to put the aircraft away in the hangar. (Sometimes local rules may have required it)

It is not just one pin - either it is 'safe for maintenance' or not. That involves moving 3 pins per seat.

Alber Ratman

29th Jan 2014, 13:50

So the aircrew move all the pins on a Hawk? The firing handle pin is only ever moved by the person sitting in the seat or by somebody qualified to remove it in the case of a CAT B passenger. I stand corrected on the Mk 10 (a seat I had only one brief on and that was from the example on a Tornado GR), it doesn't have a main gun sear (being completely gas operated), so apologies for that ignorance. Seat Handle, MDC and Man Sep?

Background Noise

29th Jan 2014, 14:05

There are 6 pins in total per cockpit. 3 servicing pins (main gun, man sep and rocket pack) are moved to switch between 'safe for maintenance' and 'safe for parking' states. The MDC firing unit pins (one in each cockpit) are moved by the pilot before getting in. The seat handle pin and the MDC handle pin are moved by the seat occupant once strapped in with the canopy closed and prior to starting the engine.

Alber Ratman

29th Jan 2014, 14:18

Thanks for clarifying that BN. It was standard practice on the FJ Sqns, I worked on that the aircraft would always be made safe for maintenance , cease fly. Somebody, of any trade was likely to have to do some work involving cockpit access.

goudie

29th Jan 2014, 14:32

I learned about Maintenance from that . .

On one of the safety posters, that used to be around the hangar, was the slogan 'Don't Assume, Check! If we're honest we've all assumed at sometime or other. 'Familiarity breeds contempt' is very true.
A Sgt armourer nearly killed himself, carrying out pull-off checks on the seat -pan handle. He took another armourer's word that the cartridges had been removed. It was the nav's seat on a PR9 and luckily he was thrown back, away from the seat. The laid down safety procedures had been severely ignored!

Chugalug2

29th Jan 2014, 15:33

BBC News:-
Martin-Baker knew the parachute mechanism could jam if the nut and bolt were too tight as early as January 1990, the inquest was told.

It seems illogical indeed that such a simple fault was not known by the UK Military Airworthiness Authority, aka the MOD/MAA. It seems illogical that the seat manufacturer would not have informed its major customer while informing its minor ones. It seems illogical that even were it not so informed, that the UK Military Airworthiness Authority, aka the MOD/MAA, would not have become aware over a period of 23 years.

As Nutloose suggests, the informing would have been by signal or other written means. The address lists of either would have confirmed or disproved the verbal evidence given in court. Were they presented? Do they exist?

Alber Ratman

29th Jan 2014, 15:54

You would have suspected that MB would have that on archive..

EGLD

29th Jan 2014, 16:31

...

nevermind

tucumseh

29th Jan 2014, 16:41

59 recommendations in the SI report. All accepted apparently.

I wonder how many fall into the "mandated policy anyway" category. Most in the Nimrod Review did.

reidchelt

29th Jan 2014, 18:09

Are we going to find out whether the pilot was strapped in when the seat fired, and killed by a badly maintained parachute link. In which case why did the seat fire.

If he trod on an improperly pinned seat handle then the failure of the chute to deploy did not affect his fate. Presumably the proper questions will be asked. The press doesn't seem to have much of a handle on it.

Alber Ratman

29th Jan 2014, 18:43

The pilot was strapped in. He can do that himself if away from base by himself, but it was at Scampton so his mechanic would have helped him with the shoulder straps and anything else he requested. Seat firing handle pin must be in. It is everybody's responsibility to check the relevant seat pins are in place before they get into the seat, aircrew more so as they have to remove the pins and stow them from safe for parking to live (Safe for maintenance has recently been mentioned). As others have said, he would shut the canopy and remove the last pins to make his canopy MDC and Seat firing handle live. The SI report should have the statements of the liney as the main witness to the incident. I have handled Hawks before, on a VASS, so remember some of the pre flight checks requiring ground help, but cant remember if the pilot would show pins before stowing them (13 years has past). I do remember we were always instructed to move well away from the lid as it was being closed, in case MDC did fire off (like the Tornado). The lid was shut on the Hawk. The SI report will hopefully fill the missing holes in as much detail as it can. Seems some here have already seen the contents.

bvcu

29th Jan 2014, 18:43

srobarts

29th Jan 2014, 18:44

Are we going to find out whether the pilot was strapped in when the seat fired

The report from the inquest says he was strapped to the seat:

LIVE: Red Arrow Sean Cunningham inquest: Team-mates could only watch in horror | Lincolnshire Echo (http://www.lincolnshireecho.co.uk/Red-Arrows-inquest/story-20422638-detail/story.html)

Rakshasa

29th Jan 2014, 18:45

One_of_the_Strange over on ARRSE brought up a good point regarding the 'illogical' faliure to inform MoD:

Well, I worked for them in the 90's and based on that I wonder whether or not the coroner was aware of the seismic changes that occurred around then in the way the UK handled such things. Back in the day (pre Eurofighter) qualification and acceptance of seats for the UK forces was done by Bedford and Boscombe Down using their aircraft, facilities and staff. That would certainly have been the case for the original 10B Hawk seat. There was also a high degree of involvement by the Institute of Aviation Medicine in many of the details. So MBA would never have been involved in signing things off and would have not have dealt directly with the user.

Arrangements differed for export customers, depending on exactly what they wanted to pay MBA for and what they wanted to do themselves. But again in the back of my mind I have the feeling that export users would be far more likely to be sent stuff directly from MBA as they were quite happy to have MBA qual the seat for them and handle all technical issues.

So, all that was fine and dandy as long as it lasted. But then Bedford closed, Boscombe shrank to a shadow of it's former self and (when I dealt with them) their fleet of three test aircraft and tens of staff had shrunk to half a graduate and some filing cabinets. Which I pillaged one day as part of some work we were doing for the MoD to find that only a rather sparse set of documentation remained. I think it was the first time we'd seen any of it, and we were doing the work as the MoD was no longer able to do anything like it any more. Oh, and the Institute of AM had become a School and the decades of experience they used to have had walked.

Then of course we have the slow death of airworthiness in the MoD as detailed in the Haddon-Cave report. Past my time of course, but not an environment conducive to the painstaking attention to detail needed to catch this sort of problem.

Now, MBA certainly had (maybe they still do ?) a reputation in some quarters as a bolshy bunch of bastards to work with but that bolshiness consisted of telling various customers and airframers that they were talking nonsense and would they kindly shut up and listen to someone who understood the problem. They still exist as a company because they get things right, and Air Forces tend to be run by people who look favourably on that attitude towards escape systems.

So I firmly believe that if MBA knew there was a problem in service they'd have made noises, and lots of them. However, if they'd sent the paperwork to an organisation in turmoil and it got binned, fell between the cracks I wouldn't be surprised at all. Maybe they just assumed that the system would work as it always had done without realising that it wasn't any more.

clicker

29th Jan 2014, 18:46

Has it been confirmed that MB omitted to tell the RAF altogether or could it have been a case of the information going to the wrong place and getting ignored as in "send three and four pence, we are going to a dance".

NutLoose

29th Jan 2014, 19:00

Yep, which I wondered earlier, it wouldn't surprise me in the least if the signals / faxes / emails were being sent to dead addresses, or they were simply missed of the mailing list.

longer ron

29th Jan 2014, 19:44

goudie

29th Jan 2014, 20:29

emails were being sent to dead addresses, or they were simply missed of the mailing list.

With regards to the safety signal, apparently not being received by the RAF,
would not an acknowledgment of receipt be required?

cockney steve

29th Jan 2014, 21:27

@ Alber Ratman... Please could you re arrange the words in your last post, "into a well known phrase or saying" :confused: :\

@ A W Blain, re-post 201....I attended an inquest on Dec. 5 th. The Coroner informed that they no longer issue a "verdict" but a "conclusion"
Where there is not a single, definitive cause of death, he files a Narrative Conclusion.......The Death Certificate has only just been issued, so I don't yet know the format.
As you said, Coroner can make recommendations,but their job is to ascertain cause of death, not to apportion blame.....but in the course of disseminating the information that led to his conclusion, the finger can point clearly!

Edit: A.R's post has been deleted.

tucumseh

30th Jan 2014, 06:31

when this era of aircraft were designed and the manuals written the system was completely different. They were maintained by fully skilled people. The manuals didnt specify every task the way they do now. I was in KSA for the start of Hawk ops using the old USAF trade system. The manuals didnt comply so we were forever raising amendments to Bae , Tornado was similar.This is spot on. Like much MoD documentation, an assumption of a certain level of competence and training exists. However, the training and experience has been diluted, and competence eroded. This was a quite deliberate policy in the early 90s and no blame is attached to maintainers.

Also, "raising amendments" (actually, requesting that ATP progress amendments via the PDS contract, with the parallel task of updating the safety case) does not actually guarantee anything will be done, as the funding was slashed in 91/92, and then removed for a long period altogether in 93. The work that the Chief Engineer ruled should not be funded was not retrospectively carried out, which means gaps exist. The relevant procedural Def Stan (another example of something that assumed a level of training) has long been cancelled, without replacement.

The SI report recommends - training courses. :ugh: Training courses are FAU if the personnel system permits "managers" to skip their first 5 grades, and not require them to catch up on all that training and experience they've missed.