Martin Baker to be prosecuted over death of Flt Lt. Sean Cunningham [Archive]

dartmoorman

26th Sep 2016, 15:39

"The Health and Safety Executive (HSE) has informed an ejection seat manufacturer that it will be prosecuted following the death of Flt Lt Sean Cunningham on 8th November 2011.
HSE’s Inspector David Butter said:
“HSE has today informed Martin Baker Aircraft Ltd that it will be prosecuted for an alleged breach of health and safety law. The charges relate to the death of Flt Lt Sean Cunningham in November 2011 at RAF Scampton.
“We have conducted a thorough investigation and consider there is sufficient evidence and it is in the public interest to bring a prosecution.”
HSE was handed primacy of the investigation following a MOD Service Inquiry, investigations by the civilian and military police, and technical investigations involving the Military Aviation Authority and the Military Air Accident Investigation Branch.
Flt Lt Cunningham was a Red Arrows pilot. He died after his ejector seat initiated during the pre-flight checks of his Hawk XX177 jet while on the ground and stationary at the Lincolnshire airbase.
Martin Baker Aircraft Company Ltd, Lower Road, Higher Denham, bear Uxbridge will appear at Lincoln Magistrates Court, date to be confirmed, to face a Section 3 Charge under the Health and Safety of Work Act." ..... from the HSE website .

Distant Voice

26th Sep 2016, 15:41

If I remember corectly, from the inquest, a safety case for the Mk10 seat did not exist making it not airworthy; MoD responsiblity. I understand that the same seat is fitted to the Tornado.

DV

PDR1

26th Sep 2016, 15:42

I suppose the most favourable outcome now would be for the fine detail of the problem/ cause to be understood and acted on [although we would hope that was done days after the tragedy], and that any fine was transferred without delay to the victim's family.

In this context a fine is just that - a fine taken into government coffers. It's not damages and so won't go to any relatives of the deceased. A criminal conviction may (or may not) open the door to a civil suite for damages by the deceased's family, but under English law they don't tend to be that lucrative so it's quite rare.

From the way this has emerged it would seem that the HSE have found something specific which MB allegedly did or omitted to do that was directly related to the hazard. If there was a technical thing which was known to be needed but not done for commercial reasons that would make prosecution of the directors (who have the duties of care in this respect) would seem the appropriate thing to do to remind them of their actual obligations.

PDR

PDR1

26th Sep 2016, 15:48

but it does seem HSE pursue a witch hunt at every opportunity.

Can I just say that in *my* experience (for what it's worth) the HSE don't pursue anyone unless there is a clear issue and a definite public interest in doing so? I would suggest that (if anything) they don't act often enough.

YMMV,

PDR

overstress

26th Sep 2016, 15:54

I understand that the same seat is fitted to the Tornado.

The mechanism that failed in the Red Arrows accident is different to the seat in the Tornado, where the scissor shackle is gas operated. If my memory serves me correctly.

tucumseh

26th Sep 2016, 15:58

Distant Voice is correct. There was no Safety Case. It follows that the Release to Service was invalid.

Something else is going on here. In 2013, before the inquest, the CPS announced that, after all the investigations noted by the HSE, there was insufficient evidence to bring any prosecution. So, what new evidence has been uncovered?

Distant Voice

26th Sep 2016, 16:07

The mechanism that failed in the Red Arrows accident is different to the seat in the Tornado, where the scissor shackle is gas operated. If my memory serves me correctly.
I am not sure when that modification was introduced. Was it pre 2013?

DV

Chugalug2

26th Sep 2016, 16:14

DV, I think that the modification to the Tornado Mk10 seat, as described by overstress, was not carried out on the Hawk seats. I agree with you that the MOD should be in the dock. Scandalous that there was no Safety Case for the seat.

dartmoorman

26th Sep 2016, 16:22

MOD and MAA full report here :-

https://www.gov.uk/government/publications/service-inquiry-into-the-accident-involving-hawk-tmk1-xx177

overstress

26th Sep 2016, 17:02

I am not sure when that modification was introduced. Was it pre 2013?

The Tornado seat was designed that way. It uses the Mk 10A seat, gas operated. I last flew one in 1994.

jumpseater

26th Sep 2016, 17:20

I seem to recall there being an issue with some of the adjustment (Tourqe) setting of the shackle assembly. Data was passed to some customers, but not the RAF or RAFAT specifically. If my memory is correct then that might be the issue HSE are targetting, the failure to communicate correct procedures for use of their equipment.

hoss183

26th Sep 2016, 17:26

In reading the report, i can imagine the prosecution relates to the finding 1.4.2.26 d "The panel concluded that the ability to initiate ejection in a manner different to the design intent was a contributory factor in the accident"
So not new evidence, but perhaps an argument for a design flaw. Its also mentioned that more modern designs have an unsafe position indication.
If the main chute had deployed we would probably not even be talking about this, but very sadly when the holes in the cheese align, bad things happen.
My personal opinion is that without MB and their excellent products many more pilots would have died to date, and it's therefore sad to see this action.

Haraka

26th Sep 2016, 18:05

1.4.2.26 d "The panel concluded that the ability to initiate ejection in a manner different to the design intent was a contributory factor in the accident"
The fatal accident suffered by Steve Beckley with his Harrier at Yeovilton in the early 70's comes to mind.
P.S. ,Looking at Engine's thread regarding the MAA findings;
The MAA found that the CAUSE of the accident was the inadvertent ejection due to displacement of the seat pan handle.

Beckley wasn't strapped in his seat IIRC, but may have trodden on the seat pan handle.

Engines

26th Sep 2016, 18:08

May I try to offer some background and analysis here, particularly on the findings of the MAA report...As Tuc observes, something is going on here. The HSE intend to prosecute Martin Baker, not the MoD or the RAF. However, the MAA's report doesn't contain much that would obviously 'hang' MB. But as for the MoD and the RAF...here's my take.

Firstly a bit of data. MAA reports define their accident factors via the following categories, in descending order:

Cause - the event that led directly to the accident
Contributory - Factors that directly or indirectly made the accident more likely
Aggravating - Factors that made the outcome of the accident worse
Other - None of the above, but could cause, contribute or aggravate a FUTURE accident
Observations - factors not relevant to the accident but worthy of consideration to promote better working practices

So, trawling thought the report, here is my summary of what the MAA came up with. I've focussed on the technical aspects that might affect any MB liability. Caps used for clarity.

1. The MAA found that the CAUSE of the accident was the inadvertent ejection due to displacement of the seat pan handle. Various CONTRIBUTORY factors were identified around the SPH design and use in service, also strap positions.

2. The reason that the pilot died was the failure of his parachute to deploy, due to an overtightened drogue shackle. This risk was known to some in MB, but not, apparently, to the MoD. The MAA found that 'Poor communication between stakeholders and the lack of a robust system of tracking amendments..(which) restricted the flow of safety critical information' was an AGGRAVATING factor. They also found that the shackle dimensions, combined with extant MoD guidance on nut fitment led to an interference fit. Shackle dimensions were thus judged an AGGRAVATING factor.

3. The reason that the shackle had been overtightened was RTI/Hawk/059D, which required the shackle to be disassembled every 50 flying hours to allow an NDT examination of a potentially cracked seat beam. The report reveals that although MB recommended a 14 day visual inspection, and 1710 NAS confirmed that the seat would be safe with a cracked beam, 22Gp decided that operating as such would 'undermine aircrew confidence', and so an NDT inspection was introduced. However, the report reveals 'the absence of a clear audit trail, poor Hazard Log tracking and a paucity of decisional meeting records', so MAA could find no rationale for this decision. This was stated to be an OTHER FACTOR. However, the (quite astonishing) lack of any safety case for the seat, while mentioned, is not identified as any sort of factor. If you don't have a safety case, it's not possible to conduct a proper hazard analysis of any proposed servicing change - like an RTI that regularly takes the drogue shackle apart.

4. The report makes it clear that once the original problem (seat cracking) was found MB and the technical specialists worked hard to get a mitigation out there. But, quite amazingly, the report doesn't comment on why an RTI was being used when an STI (required when MB was involved) should have been issued.

5. Finally, the report shows that RAFAT (Reds') engineering standards were not up to the mark as far as seat maintenance was concerned. Signatory and supervisory malpractices were considered to an OTHER factor, while absence of compliant engineer training was a CONTRIBUTORY factor. (Bear in mind that to compress the shackle, the maintainer had to cut new threads on the shackle bolt - this is definitely NOT good practice).

My thoughts - and with the usual warning that I am entering 'opinion' territory. The first thing that astonished me was why anybody would imagine that taking a seat shackle apart, in the aircraft, every 50 flying hours, was a safe thing to do. In all my years around jets, any work on a seat, especially the operating mechanisms, required a seat lift and return of the seat to the seat shop. The second thing was the absolute horlicks that happened between the HSA, the AES PT and 22 Gp in the development of the RTI. Who, in the name of all that is holy, thought that 'aircrew confidence' justified taking the risks involved in dismantling the escape system? Where was the RTI file? Where was the hazard log entry management? Where were the records of decisions? WTF?

I honestly don't buy the MAA's analysis. Here's my stab:

1. If the shackle had worked, this would have (very probably) been an incident, with the pilot surviving. It became an accident because he died. He died because his parachute didn't deploy. It failed to do so because the drogue shackle had been disassembled and on reassembly overtightened to such a degree that it jammed. The jammed shackle was, in my view, the CAUSE. The inadvertent operation of the SPH was a CONTRIBUTORY factor. (But see below)
2. The only reason the shackle had been disassembled was the RTI. I see the failure to issue a satisfactory STI as the main CONTRIBUTORY factor.
3. Lack of a safety case and a proper system for developing the STI were AGGRAVATING factors.
4. The shackle was overtightened because the information available to the maintainer wasn't complete. And the maintainer wasn't properly trained to do this job. Those, in my view, are also AGGRAVATING factors.

So, where would this leave MB? The worst that they appear to be on the hook for is not getting a certain piece of technical information out to the MoD, which may have been an aggravating factor. Or more probably, the seat pan handle design. Again, the lack of a safety case, which would have highlighted the hazard and shown the mitigations, is a key factor. In my view, the MoD and the RAF are a good bit further up the chain of responsibility here. The Reds' maintainers didn't do a great job, but they were really put in a bad place by a series of failures higher up the chain. Including systemic failures in the airworthiness management systems in the MoD and the RAF.

OK, I'm done, and apologies for the long post. Any thoughts out there?

Best regards as ever to those keeping things safe,

Engines

Trash 'n' Navs

26th Sep 2016, 18:26

Spot on Engines.

The MAA not finding fault with itself or those in the MOD - who'd have guessed that?!

superplum

26th Sep 2016, 18:44

Chugalug2

26th Sep 2016, 18:48

I totally agree with your analysis, engines. Indeed I can't see how anyone can reasonably disagree with you, as everything that you say is verifiable. I also agree with both you and tuc that something is going on here. If MB are going to be dragged to court then they have little to gain by keeping quiet, as they might have otherwise. So is that why HSE have done a 180? Are we at last to see the UK Military Air Regulator forced to account for its actions, or lack of them? Or will the establishment close ranks and form squares yet again?

Tinribs

26th Sep 2016, 19:46

As a qualified H&Safety risk assessor with 15K hours, mostly jet I feel entitled to an opinion which members may of course accept or reject

It seems to me that MB were obliged to design a seat which performed as nearl as possible to spec. When informed of problems they should rectify them as soon as possible. This seems to cover the shackle situation. certainly in my day JP Victor Canberra etc we were taught to check the "floppiness" of the shackle.

Considering the pins we always placed them in a designated location and I cannot see why an audible warning could not have been installed such that some type specific action would activate it. Say opening the canopy without the pins removed from the flight block, obviously this would not have been infallible but no seat modification would have been needed and the process easily understood.
Perhaps the audible warning could have been repeated to a sounder outside the aircraft that the seat was unsafe enabling linees to co-operate

tucumseh

26th Sep 2016, 20:03

If I may add one observation to Engines' excellent summary.

An RTI is only permitted if the Design Authorities (Martin Baker and BAeS) do not need to be involved in any way whatsoever. A 50 hourly maintenance regime on a safety critical escape system most definitely does not fall into this category.

Engines

26th Sep 2016, 20:31

Tuc,

Thank you for, as ever, timely and accurate addition to my overlong post. The newer MAP-01 regs aren't quite as clear cut (I think) but the main thrust is clear - if the DA is involved, it's an SI or an STI.

What's much clearer is what is supposed to happen when putting together any TI. I quote from MAP-01, Chapter 10.5.1 Para 1.1:

Prior to issuing an SI(T) (which includes RTIs) the TAA in conjunction with the Release to Service Authority (RTSA) and Handling Squadron (HS) must assess its effects on the Air System Safety Case, RTS and handling and operation in accordance with RA 5405.

So, when the HSA issued the RTI, who certified that they had assessed its effects on the safety case for the seat? They must have done, to issue the RTI as per MAA regs. But there WAS NO safety case for the seat. This is a clear failure of the HSA's airworthiness management process. And where was the RTSA? Did they also not know that the seat didn't have a safety case? And where was the MAA? When they assessed the HSA and the seat PT, how come they didn't spot that there was NO safety case?

Come to that, how did the RTSA issue an RTS in the first place without a seat safety case? How did ACAS sign that one off?

Once you start digging, you don't stop until you find the truth.

Best regards to all those who care, and do their best.

Engines

Just This Once...

26th Sep 2016, 21:03

Engines - nail on head. If you pull the thread of thought regarding the seat safety case (or absence of) a little harder you will find a whole lot of people talking about how robust it was at the Mike Harland inquest. Yet a little while later we all found out that no such document actually existed, nor was one hastily crafted after Mike's death. They even got the RAF Chief Engineer to say how good MB were at managing the seat airworthiness.

No safety system, no lesson learned and then another death.

dctyke

26th Sep 2016, 21:10

Engines has given an excellent summary of the tech bits. What has not been mentioned throughout, is the diminution of the AAES technical knowledge across the plumbers' trade. That is partly the result of a more centralised, and/or contractorised, maintenance programme Does RAF Scampton have a seat bay (?), I believe not and the opportunities to gain such knowledge are few nowadays. Also, IIRC, on older design seats, the shackle bolt was shouldered and could not be over-tightened as such.

As you rightly say all the seats I serviced up to mk9 had shouldered bolts, incredible they should choose not to use them. Also in the days of seat bay that bolt was never touched as the shackle was release by firing off the barastat unit. Something that could not be done 1st line, hence the work around.

Davef68

26th Sep 2016, 21:22

Can I just say that in *my* experience (for what it's worth) the HSE don't pursue anyone unless there is a clear issue and a definite public interest in doing so? I would suggest that (if anything) they don't act often enough.

YMMV,

PDR

I would concur. Too much of what is blamed on 'Elf and Safety' in the press is actually Insurance or risk aversion. The HSE do a damned fine job and they don't bring prosecutions very often.

I do wonder if evidence or findings in the inquest have led to this, although i didn't follow the case that closely.

Easy Street

26th Sep 2016, 21:34

Engines,

Purely out of interest, I note that you have adjusted your stance slightly since the same issues were discussed (http://www.pprune.org/military-aviation/531572-flt-lt-sean-cunningham-inquest-35.html#post8344440) on the original inquest thread, with you now being aligned precisely to where Chug was (http://www.pprune.org/military-aviation/531572-flt-lt-sean-cunningham-inquest-35.html#post8342504) in Feb 2014. However I agree entirely with Chug's (and your!) assessment that the drogue shackle overtightening was the cause of the accident, with the inadvertant ejection being a contributory factor, and that the semantics do matter. It will be interesting to see whether the SI's analysis stands up to the judicial scrutiny it might end up receiving in this case.

Some of the comments in this thread already hint toward a theoretical defence from MB along the lines of "yes, there was a flaw in the firing handle design, but it was a zero-zero seat and the death was caused by MOD failing to maintain the drogue shackle properly". However that defence would only get MB so far when you consider that the seat is supposed to be safe to sit on when the aircraft is inside a shelter or hangar; a design flaw which allows inadvertant ejection in those circumstances could not possibly be mitigated by deflecting blame further down the ejection sequence. So it will be very interesting to see whether the charge relates to the seat pan firing handle design or the drogue shackle bolt tightening procedure: if the former, MB may well be in trouble.

It's a very different story if the charge centres on the drogue shackle bolt. I can remember being advised at some point during training on Mk10-equipped aircraft (either at Valley or on the Tornado OCU) to check the drogue shackle for freedom of movement during the pre-flight check of the ejection seat. I can't recall this being written down in any of the APs and my memory is of it being just another piece of received aircrew wisdom. However if anyone has kept a set of Hawk or Tornado FCCs from that era it would be very interesting to see whether 'free to rotate' or words to that effect are mentioned in connection with the shackle. I also remember direction being issued in the mid-2000s, as we entered a brave new world of safety, that ejection seat components should not be touched during the pre-flight checks unless specified in procedures. How ironic that this more 'modern' attitude might have removed a defence against error elsewhere. But I digress... the fact that such aircrew wisdom existed in the period between 1995 and 2005 (dates deliberately widened to preserve anonymity!) shows that someone, somewhere in MOD must have been aware of the potential for overtightening of the drogue shackle bolt. If MB's trial hinges on this point we could be in for a very interesting time.

To end: I hope that Theresa May's Government, with its professed interest in preserving British industry, prevails upon MOD to approach this case with a view to minimising the harm to MB's reputation. MOD isn't going to lose any of its "business" by owning up to faults, but if it chooses to obfuscate it would risk causing severe collateral damage to a great British firm.

Engines

26th Sep 2016, 22:08

Easy,

Thanks for coming back and contributing to a very good thread. I'd like to respond to your point about my 'adjustment of stance'.

i've consistently tended towards a view that the MoD's failures with regards to airworthiness (which are systemic and serious) were, and remain are, driven more by incompetence and ignorance rather than 'malevolence'. I did not and do not believe that anyone seriously set out to deliberately cause deaths and loss of aircraft. However, I do believe that decisions made by senior officers (and senior civil servants) to advance their own careers ('look how many millions of pounds I've saved by transformational change to my PT!') have led directly to those deaths. They continue to happen, and almost certainly contributed to Sean's death.

Where I do support the use of the term 'malevolent' is the ongoing effort to cover the whole issue up. Reputations are blackened, facts are suppressed and lies are told. In my view, that's probably going to be the thing that gets them in the end. Cover-ups usually do.

Incidentally, I clearly remember being briefed on seat pan handle safety on the Mk10 seat in the 90s, with a clear instruction to check that it was fully home before inserting the seat safety pin, and making sure it stayed that way after pin withdrawal. That was risk mitigation happening at the local level.

But here's the REAL point. If the seat HAD had a safety case, the issue of the seat pan handle would have undoubtedly been noted and recorded in the Hazard Log. That hazard would then have been 'sentenced' - that is, investigated, analysed and mitigated, against the extant Safety Case and build standard, with full input from the Design authority. Except, as Tuc would gently point out, the main mechanism for doing this activity (PDS contracts) was effectively cancelled from around 93 onwards. And, as late as 2011, the seat didn't even have a Safety Case, so none of this activity could have taken place anyway.

Hopefully, this one will run and run. Best Regards as ever to those keeping our aircrew safe right now.

Engines

Trash 'n' Navs

26th Sep 2016, 22:10

the seat is supposed to be safe to sit on when the aircraft is inside a shelter or hangar

It's designed that way so "inadvertent" activation is either down to the design, maintenance or operation of the seat.

It seems odd that HSE have only focused on the designer when maintenance & lack of a safety case clearly contributed - if not caused this.

Tango837

27th Sep 2016, 01:01

Jumpseater is correct, at the inquest it was stated that MB notified all users of the seat that there was a notice about the torque loading of the shackle except
the RAF and RAFAT were unfortunately omitted from the message. MB were
notified of the problem of shackle bolts in June 1992 .

AtomKraft

27th Sep 2016, 09:34

Reading the report, I can see that his seat malfunctioned, as discussed in the thread- but not why it fired.

It seems to me that after completing his 'full and free' check, he brought the stick back sharply and his seat fired about 3/4 of a second later.

Why did it do that?

Timelord

27th Sep 2016, 10:06

AK - It is all in the report, but to summarise; On a previous sortie the lap straps had been routed through the handle with the result that it had been partially pulled, but not enough to fire the seat. After that sortie the pin had been inserted in a way that DID NOT render the handle safe. Numerous checks failed to reveal the incorrect fitting of the pin and on the day of the accident it only took a "nudge" from the full and free check to cause the seat to fire.

EAP86

27th Sep 2016, 11:14

Tuc, the CPS prosecute as a result of the findings of the Police investigation. The HSE have the power to initiate prosecutions as a result of their investigation. Not many Agencies have this power, the only other which comes to mind is the CAA. In general the HSE only act when they find evidence of a gross breach of the duties in the HASAWA. This is a pretty tough test and such prosecutions aren't common. The HSE must have determined that MBA did something in breach of the duty or, perhaps more likely, failed to do something (or even can't prove that they did something).

EAP

tucumseh

27th Sep 2016, 11:47

EAP86

Thank you and agreed. In this case, it was notable that the CPS issued their statement before the Inquest and release of the SI report, so most observers were in no position to comment; least of all family. And, like others (e.g. Nimrod, C130, Chinook), the police refused to interview witnesses. To me, this suggests interference in the judicial process. As mooted above, Martin Baker may be the defendant, but probing questions will mean an unseemingly scrum to fill the dock with MoD and Ministers (I hope!). It is difficult to see how the HSE would have missed this, given the evidence before it, so perhaps it is a deliberate strategy?

Distant Voice

27th Sep 2016, 12:01

Heathrow Harry

27th Sep 2016, 12:45

" It is difficult to see how the HSE would have missed this, given the evidence before it, so perhaps it is a deliberate strategy?"

Indeed - a nice way to nail or at least embarass a lot of people who probably think they are safe and dry...............................

tucumseh

27th Sep 2016, 12:52

If there was no safety case, who signed off to say that the risks associated with th operation of the Mk10 ejection seat were Tolerable and ALARP? This must affect all aircraft fitted with the same type of seat.

And, as stated above, it follows there can be no valid Hawk safety case, and hence no valid Release to Service. As I said, it is inconceivable the HSE don't realise this will be raised in court. Perhaps the HSE don't think this is a gross breach (nod to EAP86) but I suspect those who rely on a robust RTS do. A false declaration on the RTS? Been there before, haven't we? Chinook. Nimrod. Sea King. Tornado..........

NutLoose

27th Sep 2016, 13:39

So with this pending prosecution, are we to assume that all the seats have been modified since to remove the problem? Or are there still issues with them?

India Four Two

27th Sep 2016, 13:50

Also, IIRC, on older design seats, the shackle bolt was shouldered and could not be over-tightened as such.

sugarplum,
That's very interesting. I've always been interested in ejection-seat mechanisms, doubly so since I rode a live seat many years ago, in a Vampire T11. So when I read the report about the Scampton accident, I found it hard to believe that anyone would design the shackle without a shouldered bolt.

Two general questions about Safety Cases. I've just looked them up on Wiki and ended up more confused than before.

When were Safety Cases introduced into the RAF?

Is there a public domain Safety Case that I can read?

dctyke

27th Sep 2016, 14:03

A little bit of background with seat servicing. When hawk seats were first in service they went to the station seat bay every six months for inspection/servicing. This was then extended to twelve months, then over time twenty four months. At that point at least the seat bay staff on base could go out to the sqns and inspect and advise if there was a problem (which did increase with the 24 month servicing cycle). Then they shut down the bay's for centralised servicing and gradually lost the expertise on units. In the early years of the hawk, ejection seat maintenance training was deleted from armament technician training and seperate course introduced for those destined to work in a seat bay. This made for few trained staff which gradually got less over the years after the bay's closed. Not for one minute saying this would have made any difference whatsoever to the incident, it's just a fact, I'm sure better folks than I looked in to it and declared it good practice and saving a shed full of money.

Wander00

27th Sep 2016, 14:23

I42 - You and me both. In my uninformed way, I assumed someone in MoD said build a Rolls Canardly Mk II, Somewhere Dareospace built it, AAEE tested it to make sure it is up to spec and worked and was safely built. Ditto components like seats. Occasionally someone designed something, which someone else checks but although working with best endeavours cocks it up and the system is dangerous, eg fuel link up from probe in the Nimrod. Where does the "safety case" fit in, what does it do?

langleybaston

27th Sep 2016, 14:52

Please for the ignorant may we have a definition of a Safety Case?

Engines

27th Sep 2016, 15:34

Langley,

i'll try to help. And it's not ignorance - there's a lot of definitions out there. Wikipedia supplied this generic definition, taken from UK Def Stan 00-56:

A Safety Case is a structured argument, supported by evidence, intended to justify that a system is acceptably safe for a specific application in a specific operating environment

00-56 is still extant and often called out in contracts. This is a perfectly usable Standard, but the MAA decided to go their own way and create a bespoke set of regulations for air safety management. Their definition is set out in RA1250 thus:

An Air System SC is an up to date, through-life body of evidence that presents a coherent safety argument that demonstrates that all credible RtL associated with an Air System have been identified, assessed and mitigated satisfactorily.

In aircraft terms, a Safety Case is written around a defined system (defined by its build standard) and its specific application is set out in the requirements against which the system (aircraft) was designed. The safety case may also include limitations against the original requirement to manage identified hazards. Evidence will include analysis, component testing, demonstrations, rig tests, ground tests, and finally flight test. It can also include read-across from other systems. It can also be supported by safety cases for individual equipments (like ejection seats) or, further down the chain, chunks of evidence sometimes called safety statements.

The chain then moves on, with Build Standard (configuration) and the Safety Case being used to build the Release to Service (RTS) recommendations, which the RTS Authority uses to build and release the RTS.

What this means is this: when you go and sign for an aircraft, you should be able to assume that the equipment you are strapping into has been thoroughly analysed, tested and certified as safe to use within the limitation in your publications. That's what the RTS should give you. Moreover, you should be able to assume that if anyone in your command and engineering chains have changed the configuration (or servicing) of the system, then that change has been fully checked, tested and analysed against the current safety case. Again, you get this via the RTS.

I hope you can see why people like Tuc and Chug (and me) have been so vocal about this one. The MoD did not hold a Safety Case for the Mk10 seat. If they didn't hold that, they should never have issued an RTS for the aircraft. As Tuc has said elsewhere, it's highly probable that Martin Baker had a perfectly good 'Safety Statement' for the seat, to get it past their own internal safety management system. However, that document may not have been kept up to date, or supplied to the MoD, as the funds to support that activity were slashed in 1993. So, somewhere between the Mk10 entering service and 2011, the MoD ceased to have a Safety Case for the seat. The public needs to know why. And ACAS needs to explain how he issued an illegal RTS.

Best Regards as ever to those working hard to keep our people safe

Engines

Edit - Tuc got in just after me with an even better response. Hope these help.

tucumseh

27th Sep 2016, 15:35

LB

The Safety Case is a structured argument, supported by a body of evidence, that provides a compelling, comprehensive and valid case that a system is safe for a given application in a given environment.

I've quoted Def Stan 00-56, but for example Boscombe Down and Westland use "Is the study of an aircraft or item of aircraft equipment to identify and show acceptability (or otherwise) of the potential hazards associated with it. The Safety Case provides a reasoned argument supported by evidence,establishing why the Design Authority is satisfied that the aircraft is safe to use and fit for its intended purpose". It is used to assist A&AEE in making (airworthiness) recommendations for a particular standard of aircraft".

Personally, I like the latter definition, mainly because it specifically mentions the build standard. Also, because it makes clear the Design Authority's responsibility, and talks of both aircraft and aircraft equipment (which MoD makes provision for in separate ways). In other words, the Def Stan was too simplistic, but served its purpose in the days when the target audience were taught this stuff at birth.

However, the first version is still ok. The "application and environment" bit means that a fundamental pre-requisite is a Statement of Operating Intent and Usage. (The Chinook Mk2 didn't have one, which is one of the things that buried MoD). All aircrew are required to have read and to have access to the SOIU. It forms the basis of the Aircraft Specification which the Build Standard(s) reflect. A version of the Safety Case exists against each Build Standard (in practice, a series of call-ups are used, in the same way drawings are controlled). The Release to Service is based on the Build Standard presented for trials.

It follows that SOIU, Build Standard, Safety Case and RTS must be maintained. This glider case is all about a breakdown of the process that does that maintaining.

There is seldom a "Safety Case" in the form of a single document - especially not on aircraft systems. What you have is a hierarchy of hundreds of not thousands of Safety case reports, which the Aircraft DA collates, forming a Whole Aircraft Safety Case. Trying to keep it simple here, but in this case MB would produce a Safety Case for the seat, which BAeS would subsume into the higher level Aircraft case. It is this process that determines, for example, why the ejection seat might be safe in a Hawk, but not in another aircraft. (Where the application bit comes in). Another example - this is one of the things that buried MoD on Nimrod XV230. The AAR modification/system was safe in one application, but not in the application to which it was put in Sept 2006. Similarly, C130 XV179.

Hope that helps.

Edit - sorry, Engines got in first.

PDR1

27th Sep 2016, 15:43

Please for the ignorant may we have a definition of a Safety Case?

I doubt you will find an example of an aviation safety case in the public domain, but the [uk] requirement for them comes from standards like JSP-430 and Def Stan 00-56. The non-military HSE document R2P2 ("Reducing Risks and Protecting People") also has stuff to say about them.

As for a definition, 00-56 says:

"A Safety Case is a structured argument, supported by a body of evidence, that provides a compelling, comprehensible and valid case that a system is safe for a given application in a given environment".

That's about as succinct as it gets - the JSP version is much wordier and less clear as a result.

There is an inherent problem with safety cases - they are a verbal "argument". This means that for any complex system (anything much more complex than a penknife, actually) there are lots of words over lots of pages which need an expert to grasp, comprehend and critique. That was one of the issues in the nimrod case - the post-holder who contracted it knew exactly what should have been in it, but when it was delivered a few years later the current post-holder wasn't a safety specialist and could only assess it by weight ("thud-factor" as Haddon Cave called it).

To construct a meaningful safety case for a fast jet needs many thousands of hours of specialist engineering. Even just drafting it in any meaningful way involves a special symbolic language called "goal-structured notation" which is then fleshed out in text. Once it's created someone else then has to try to understand it to critique or approve it - arguably the only way to do this is to deconstruct it back to the symbolic form, and that takes another few thousand hours of specialist engineering effort. In the real world these skilled resources rarely exist in the quantities needed.

And of course for every slightest change in the system or its operating context the whole thing must be revisited to see if it invalidates (or just weakens) the arguments as presented.

Something like a bang-seat can't really have a safety case in its own right - it has it's contribution to the overall fast-jet training system safety case. Why? Well the acceptability of some safety mitigations can often depend on how and where it is used, stored & maintained.If the seat is sitting in stores it may be acceptable to mitigate a wear hazard under the seat pan by daily inspections, but this probably wouldn't be a viable argument when it's installed.

I know nothing about the Hawk case; the above is only a generic description of the items in question, in my personal opinion, as an engineer who happens to hold a safety engineering qualification.

E&OE,

YMMV,

PDR

PDR1

27th Sep 2016, 15:45

Well there's three engineers and three answers (although they agree in fact and differ only in opinion!).

PDR

Wander00

27th Sep 2016, 15:46

Engines/Tuc - thanks - I think I understand. But the I think I understand John Farley's book "A View From The Hover"!

tucumseh

27th Sep 2016, 15:59

If I could just add something. There are various levels of Safety Cases and Engines and I are (naturally) talking of that compiled and maintained by the DA and project teams. But you must always consider that the aircraft is not in itself a "system". A higher level system exists which includes the aircrew, maintainers and so on. The RTS includes a list of authorised Aircraft Technical Pubs for example, and it is the role of named individuals in MoD to ensure they remain valid and everyone is trained correctly in their use. So, if the FRCs are wrong (or blank as in the case of Chinook) there is a serious failure which is not the responsibility of the original designer. Similarly, if the aircraft is put to a use which is prohibited (again, Chinook) then the designer cannot be blamed. This structured approach makes it very easy to see where the breakdown occurred. In this case, I'm still struggling to understand why the HSE can't see MoD's offences. I hope MB fight their case. This could be the catalyst for the much needed scrapping of the MAA and resurrection of old, mandated policies.

tucumseh

27th Sep 2016, 16:05

PDR1

Well there's three engineers and three answers (although they agree in fact and differ only in opinion!).

Like it. But the point is, if each of us implemented mandated regulations, physical and functional safety would be assured, as far as possible. Each of us would bring our own experience and training to bear, and our approaches might differ a bit, but the output would be the same. But MoD doesn't implement its own regs, and its definition of functional safety is positively dangerous. And it would seem it doesn't require output!

PDR1

27th Sep 2016, 16:32

I have to say my own experience is different, but then my experience was primarily with the Harrier II and stopped when it left RAF service (December 2010). At that stage the MAA regime was still "work in progress" in many areas. But on the harrier platform we had a full safety case with supporting evidence that went through MAR Recs into the RTS production, and the arguments were traceable to specific features of the design & operating context. A major part of the GR9/9A/T12 upgrade was ensuring the validity of the safety case remained for the new configuration. But to do it we had a team of specialist system safety engineers, and they spent weeks working in collaboration with Harrier IPT specialists to ensure there was a common understanding of the safety case as written.

If you know of this company you'll also know that at that time each aircraft project was a separate "sovereign entity" with its own procedures and approaches, so I have no idea what they did on the Hawk projects.

Actually I was pleasantly surprised that three engineers only gave rise to three opinions - normally I'd have expected at least five...

:)

PDR

EAP86

27th Sep 2016, 16:33

langleybaston

27th Sep 2016, 16:34

Gentlemen, many thanks. I read every word, and "as of this moment in time", yes, I do understand.

Don't send the trappers in tomorrow, though!

glad rag

27th Sep 2016, 16:34

So with this pending prosecution, are we to assume that all the seats have been modified since to remove the problem? Or are there still issues with them?

Mod being rolled out via seat sets I will ask about this..

From memory I believe the Germans were never happy with the seat drogue "portion" and modified that part of the seats themselves..

EAP86

27th Sep 2016, 16:43

From memory I believe the Germans were never happy with the seat drogue "portion" and modified that part of the seats themselves..

Do the Germans operate Hawk (which has the Mk 10L seat) or do you mean the Mk10A in the Tornado?

EAP

PDR1

27th Sep 2016, 16:46

A bit of history may help. In the late 80s early 90s the ADRP commissioned a safety consultancy to review their current safety arrangements and make recommendations. I think the Piper Alpha inquiry had recently found the safety case approach quite compelling and the consultancy recommended MOD take the concept on board. The concept appeared in Def Stan 00-56 around the same time but perhaps wasn't well understood by many. I can recall confusion in PTs and it's perhaps not surprising that each ended up with a different SC approach and format. In hindsight it might be that more time could have been spent on the management of the introduction of the change. I suspect that there are still ongoing issues but that might be another thread.

That's a really excellent point which I'd forgotten about. Being anxious to re-iterate that I have no knowledge whatsoever of what they did/do on Hawk and am only speculating: It's quite possible that Hawk Tmk1a was exempted from some aspects under a "grandfather" assessment - this used to be a common approach to legacy equipment in response to changing regulations due to the absolute unaffordable of keeping legacy aircraft compliant with modern standards. It was something which HC struggled with, but I have some sympathy because countries like ours simply can't afford to replace aircraft fleets as often as these regulatory changes would require. Not when the expectation (based on recent and current types) is that the in-service life of a military aeroplane could be 30-60 years.

PDR

jumpseater

27th Sep 2016, 16:48

Engines
The MoD did not hold a Safety Case for the Mk10 seat. If they didn't hold that, they should never have issued an RTS for the aircraft. As Tuc has said elsewhere, it's highly probable that Martin Baker had a perfectly good 'Safety Statement' for the seat, to get it past their own internal safety management system.

However, that document may not have been kept up to date, or supplied to the MoD, as the funds to support that activity were slashed in 1993. So, somewhere between the Mk10 entering service and 2011, the MoD ceased to have a Safety Case for the seat.

Q from civvy.
Is this (RTS) a grandfather rights thing?
I presume MK10's were introduced and released to service prior to much of the in depth data/history systems 'we' use today. (NB I'm aware that like civvies the airframe doesn't leave the ground until its matched its own weight in paper documentation)

So if the airframe and systems/equipment were fit for RTS under a 1980's? system, have or were they subsequently re-assessed under contemporary standards? and I realise that timelines sort of a moving target.
If a mod is done to a system, eg seat cushion change, is the whole seat re-assessed or is it just the cushions and their immediate fixings?

So if an airframe is assessed in e.g. 1989, and there are no historical incidents or accidents that point to a problem area, (eg seats, in every event they've previously worked as expected), can these form a hole in the cheese if there is no regular update or overview to ensure legacy equipment is still fit for purpose.

If HSE are pursuing MB, I feel it follows that HSE feel the company has a specific case to answer regarding its product or product support, rather than how the end user operated it. Even allowing the possibility that the end users procedures/application were found also to be at fault.

tucumseh

27th Sep 2016, 16:54

EAP86

Your recall from 80/90s is spot on. ADRP (who at the time were manned by very good people) and Cranwell joined forces and everyone with airworthiness delegation was sent on a refresher course to have this stuff injected intravenously. My course was in late 1993, and it was reinforced that year by the issue of DCI GEN 89 1993 Airworthiness Responsibility for UK Military Aircraft. But as a Technical Agency, I had been given it all a couple of years earlier, around the time the Montreal Protocol was being implemented in anger, because we had to renegotiate our contracts with the DAs. (Commercial don't do that stuff when it comes to airworthiness). But the abiding memory is of my boss (the author of the only dedicated airworthiness procedural Def Stan) writing to AMSO and pointing out this new mandate increased the cost of maintaining airworthiness. AMSO's reply was to apply a further 28% cut in funding. This was noted, and criticised, by the Director of Flight Safety (RAF) in August 1992. This criticism was met by another (!) 28% cut the following year, making the Chief Engineer's position crystal clear. This is what MoD is still trying to recover from.

zerofivezero

27th Sep 2016, 18:34

MB's contribution to safety is unparalleled in the history of aviation, saving thousands of lives many of which were outside the design envelope of the seat. There were many aspects to this accident that come down to individual failings by personnel who failed to do their checks or fulfil their responsibilities correctly; the RAF is not what it was and it is shameful that they will end up hiding behind the HSE.

EAP86

27th Sep 2016, 18:42

PDR at the time there was the concept of the "legacy safety case". Roughly speaking if a type already had an extant RTS and could demonstrate a satisfactory in-service safety record, the type was deemed to have a legacy safety case. It wasn't a bad idea as a starter for 10 but it probably contributed to the plethora of different approaches. Not necessarily what you want really...

EAP

PDR1

27th Sep 2016, 18:59

gordon field

27th Sep 2016, 20:08

Excellent analysis, thanks.

NutLoose

27th Sep 2016, 20:11

Mod being rolled out via seat sets I will ask about this..

From memory I believe the Germans were never happy with the seat drogue "portion" and modified that part of the seats themselves..

Thanks, I ask because if they are saying they are culpable for knowing the fault existed and not rectifying the problem, it doesn't bode well that after it has been brought to attention of the MOD, the aircraft / seat is still in service, and that decision must also be leaving the person who made it wide open to prosecution too.

It does surprise me that the seat bay format has gone and it is now being done on the units and that dedicated seat training for the plumbers has also gone. Heck as an Engine guy posted onto a Squadron in Germany I was expected to do a three day course in the bay on the operation and servicing of the Jags seat.

gordon field

27th Sep 2016, 20:24

Upon reading the report of the events leading up to the accident it is very clear that standards have slipped at the Red Arrows and that things were rushed and over looked.

The pilot had taken over the counter medication, he was not current in two areas of training, he couldn't find his flying jacket so did without it, he took a call on his mobile when walking out to the aircraft, the RA allowed 3 mins to complete checks when other forces allow 5, he failed to remove two safety items until reminded to do so by his ground crew. RT procedures were not followed. IMHO it appears that standards have slipped at the unit and could have been a contributing factor.

The close tolerance with the shackle was a well known manufacturing/service problem known to many operators who use the same seat and though recommendations were made there was no real RED FLAG alert in place.

It is easy to become complacent when you are 'The best of the best' but the whole team
need to reassess their standards and strive to achieve a higher standard.

EAP86

27th Sep 2016, 20:31

Just ruminating in the bar over a pint reminded me of one of the complications associated with SCs. Some PTs relied on industry for integration of engine/airframe/seat but others didn't. I'm not sure whether ADRP gave any thought to how this might complicate matters. It could certainly complicate how external parties view the question of who was responsible for what.

From memory (RAF) Hawk dealt with the airframe, engine and seat DAs separately and was responsible for overall integration itself. Not sure about the RN or others. This may go some way to indicating why MBA is under the microscope in this case. Probably best not go further as this is potentially sub judice.

EAP

Bob Viking

27th Sep 2016, 20:38

Judge, jury and executioner. Case closed.

BV

AtomKraft

28th Sep 2016, 04:26

I'm surprised M-B didn't use a special bolt in that drogue shackle.

It's clear that overtightening that nut could easily happen, and a bolt with a fatter shank and then a reduced diameter threaded portion could have prevented pinching the ends.

I hope they redesign it.

tucumseh

28th Sep 2016, 04:36

EAP86 is right, HSE state the case is subjudice, so will not be releasing the finer details of the charge. They have declined to comment on what evidence they have rejected/accepted, and why, but they have firmly stated that MoD is in the clear; so it is pretty obvious (a) they haven't read the evidence, and (b) they think they have something else that has not been discussed.

Some PTs relied on industry for integration of engine/airframe/seat but others didn't. I'm not sure whether ADRP gave any thought to how this might complicate matters. It could certainly complicate how external parties view the question of who was responsible for what.I'm not sure what input ADRP had to this on ejection seats, but they had none at all on avionics, and their integration with each other and aircraft, as the policy was issued, and managed at all DAs, by the same single section in MoD(PE). Until June 1993 that is, when the section was disbanded, without replacement, the mandated Def Stan cancelled (but which remained mandated for another 15 years), and the work, if it was even carried out, became a minor task to hundreds instead of the core task of a handful. Hence the variable approach you mention.

Some might recall the Bernard Gray report, commissioned by the last Labour Govt and then picked up by the Coalition. It is why he became MoD's procurement boss. Gray trumpeted this around the media and suggested a return to this old regime, but it turned out he didn't actually know it was an old policy, and it appears one of his lackeys cut and pasted a few pprune posts in a briefing. (Not a bad strategy, but it helps if you do some research before presenting the posts as your own work). When asked about this by a Minister, MoD denied Gray had even mentioned the subject, despite his interview still being available on the Radio 4 website. My advice to MoD is swallow your pride and get some consistency back into your work.

Chugalug2

28th Sep 2016, 08:00

tuc:-
they (HSE) have firmly stated that MoD is in the clear; so it is pretty obvious (a) they haven't read the evidence, and (b) they think they have something else that has not been discussed.
Then they will be judged by the company that they keep! Hopefully MB will challenge these charges and put their case in court. Whatever the rap it should be mitigated by evidence that their prime customer has no idea how to ensure that MB products that they own are kept safe. They should have little trouble in convincing a court that that is the case.

FJ2ME

28th Sep 2016, 08:17

There's lots of good technical, legal and regulatory stuff here, and quite a lot of people obviously know more about this than me. However, to close off some rabbit holes, the HSE prosecution, from my reading, seems to rest on MB knowing about potential faults on the seat, and failing to pass that information on to the end user. I think that is where MB have let themselves down here. It's not about safety cases, conspiracy theories etc, it's a simple case of a manufacturer having experience of faults on a product related to safety, and then failing to fulfil their duty to inform the end user. Whether this be through negligence, incompetence or malpractice will be for the court to decide.

Heathrow Harry

28th Sep 2016, 09:09

I think FJ2ME has hit the nail on the head - if a car manufacturer finds something lethal about their cars they have to tell all the buyers - if MB did know they had a problem they had a similar duty

Safety cases and all the processes discussed above are ways to find, document and fix the problem but they don't get round the basic duty to your users

PhilipG

28th Sep 2016, 09:56

If FJ2ME is correct in his supposition, I have no way of knowing, the acid test surely is has since Sean Cunningham's death MB passed this information on to the users of the seats in question?

I would find it difficult to believe that the HSE after investigating MB and "finding a smoking gun" did not require MB to inform their customers, or indeed inform the customers themselves.

FJ2ME

28th Sep 2016, 10:05

It is these words from the coroner which I believe have led to the HSE prosecution. I could be wrong but he was pretty clear in his assertion...

"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.
The manufacturer warned some air forces but did not warn the MoD."

This comes from the BBC report of the coroner's inquest. Incidentally not too glowing praise for the RAF either...

http://www.bbc.co.uk/news/uk-england-lincolnshire-25943211

Distant Voice

28th Sep 2016, 10:06

According to H-C the drawing up of a ‘Safety Case’, to identify, assess, and mitigate potentially catastrophic hazards before they could cause an accident, was mandated for military aircraft and other military platforms by regulations introduced in September 2002.

I can recall confusion in PTs and it's perhaps not surprising that each ended up with a different SC approach and format.

I agree. Having seen the SCs for Nimrod and Tornado they are as different as chalk and cheese. With, in my opinion, the Nimrod SC having more substance and meaning.

DV

Distant Voice

28th Sep 2016, 10:20

I would find it difficult to believe that the HSE after investigating MB and "finding a smoking gun" did not require MB to inform their customers, or indeed inform the customers themselves.

Customers were informed by MB Special Information Leaflet No. 704 in November 2011 and 704A in November 2013. Seeing as the accident happened on 8th November 2011 it is clear that the cause of the accident was known about, almost immediately.

DV

PhilipG

28th Sep 2016, 10:51

Customers were informed by MB Special Information Leaflet No. 704 in November 2011 and 704A in November 2013. Seeing as the accident happened on 8th November 2011 it is clear that the cause of the accident was known about, almost immediately.

DV

Thanks for the clarity, being pedantic, does anyone know what communication mechanism MB had previously used to inform the non MoD customers of the problems with the seat? Was there a previous SIL that went out but not to the MoD?

Chugalug2

28th Sep 2016, 10:54

DV:-
Customers were informed by MB Special Information Leaflet No. 704 in November 2011 and 704A in November 2013.

House of Commons Hansard Written Answers for 10 Mar 2014 (pt 0002) (http://www.publications.parliament.uk/pa/cm201314/cmhansrd/cm140310/text/140310w0002.htm)

Military Aircraft

Angus Robertson: To ask the Secretary of State for Defence when his Department received copies of Martin-Baker's Special Information Leaflets, SIL 704 and SIL 704A; and what steps it has taken to incorporate the revised checks into the appropriate maintenance publications. [190344]

Mr Dunne: Special Information Leaflet (SIL) 704 was received on 15 November 2011 and SIL 704A on 18 November 2013. Corresponding Ministry of Defence (MOD) Technical Instructions were issued on 16 November 2011 and 5 December 2013 respectively to ejection seat maintenance units. Both Technical Instructions mandated checks of the ejection seat drogue shackle that were more stringent than those laid down in the SILs. In both cases, amendment action to the appropriate MOD maintenance publications commenced soon after issue of the Technical Instruction.

Angus Robertson: To ask the Secretary of State for Defence if he will place in the Library a list of Martin-Baker's Special Information Leaflets, with contents summary, issued between 1990 and 1996. [190345]

Mr Dunne: Martin-Baker Aircraft issues Special Information Leaflets (SIL) to the Ministry of Defence as a contract deliverable for each aircraft type. The Department does not therefore necessarily receive a copy of every SIL issued by the company. Information on SILs relating solely to aircraft types and equipment that are no longer in-service is not held centrally and could be provided only at disproportionate cost. A list of those SILs that are known to have been received by the Department between 1990 and 1996, with contents summaries, will be placed in the Library of the House.

https://mail.google.com/mail/u/0/?ui=2&ik=97a0e014ff&view=att&th=14468d1dbbeec83a&attid=0.1&disp=safe&zw

https://mail.google.com/mail/u/0/?ui=2&ik=97a0e014ff&view=att&th=14468d1dbbeec83a&attid=0.2&disp=safe&zw

NutLoose

28th Sep 2016, 10:57

"It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety."So working on that scenario, you could prosecute every manufacturer of any weapon system from Aircraft to a lowly bow and arrow, as you are putting persons in danger of getting shot, bombed, speared or generally killed, and I won't even mention the lead content of a round that far exceeds the legal limit for ingestion.

overstress

28th Sep 2016, 11:04

it is clear that the cause of the accident was known about, almost immediately.

I believe all Mk10 equipped aircraft were grounded immediately after this accident, but soon after, the Tornado was cleared to fly. (different mechanism). The Hawks remained grounded.

PDR1

28th Sep 2016, 11:33

So working on that scenario, you could prosecute every manufacturer of any weapon system from Aircraft to a lowly bow and arrow, as you are putting persons in danger of getting shot, bombed, speared or generally killed, and I won't even mention the lead content of a round that far exceeds the legal limit for ingestion.

In this case the duty of care "so far as is reasonably practicable" is discharged by ensuring that the customer/user to whom your product is sold has procedures and controls to mitigate that risk.

PDR

tucumseh

28th Sep 2016, 13:26

Martin-Baker Aircraft issues Special Information Leaflets (SIL) to the Ministry of Defence as a contract deliverable for each aircraft type. The Department does not therefore necessarily receive a copy of every SIL issued by the company. Information on SILs relating solely to aircraft types and equipment that are no longer in-service is not held centrally and could be provided only at disproportionate cost. A list of those SILs that are known to have been received by the Department between 1990 and 1996, with contents summaries, will be placed in the Library of the House. Key words - "contract deliverable". Key question - Was there a suitable and continuous contract in place? The funding for such contracts, as I've said many times, was chopped by 28% in three consecutive years, and the centralised management of this work stopped in June 1993. At the same time, the oversight committees were disbanded and the Agency contracts (paying specialist companies to collate and distribute such technical papers from Design Authorities) cancelled.

The admission the papers are "not held centrally" confirms what I've said. The question should be "Why not", because the regulations require them to be, and all procedures assume them to be.

edit: just removed an unnecessary bit.

zerofivezero

28th Sep 2016, 14:09

SirPeterHardingsLovechild

28th Sep 2016, 15:01

Hi Engines, I disagree with your analysis at #26

1. The MAA found that the CAUSE of the accident was the inadvertent ejection due to displacement of the seat pan handle. Various CONTRIBUTORY factors were identified around the SPH design and use in service, also strap positions.I honestly don't buy the MAA's analysis. Here's my stab:

1. If the shackle had worked, this would have (very probably) been an incident, with the pilot surviving. It became an accident because he died. He died because his parachute didn't deploy. It failed to do so because the drogue shackle had been disassembled and on reassembly overtightened to such a degree that it jammed. The jammed shackle was, in my view, the CAUSE. The inadvertent operation of the SPH was a CONTRIBUTORY factor.I mentioned this on the original thread.

The Service Inquiry is into the "Accident involving Hawk XX177 on 8 Nov 11" that led to the death of Flt Lt Cunningham

The CAUSE must be the "inadvertent ejection due to displacement of the seat pan handle"

Why? Because the same event could have happened to a member of the ground crew earlier in the timeline. He would not have been strapped in
so the shackle would have had no bearing on his death or injury. Forgive my flippancy but Flt Lt Cunningham could have landed on the Families Day bouncy castle.

I'm on your side, and all the other who agreed with your analysis, but I believe the MAA got it right.

Single Spey

28th Sep 2016, 15:25

SirPeter....,

In this accident I am with ENGINES. If the sequence of events that you describe had taken place then the CAUSE of that 'accident' may well have been different. But it didn't so I don't believe you can ascribe a CAUSE based on something that didn't occur.

SS

Engines

28th Sep 2016, 15:56

SPHL,

Thanks for coming back and happy that you disagree - that's what a discussion thread is for. I think that in cases like this there will always be an element of policy and direction - often this is saying no more than 'this is how we are going to do things'. And this will be different across organisations.

In the case of MAA SI reports, I believe that the format currently adopted tends to make the reports less easily readable. This one was typical, with no list (that I could find) of the accident factors - you have to plough through the text to find them.

Hoever, I will try to justify my view of the factors. My reasoning goes like this:

1. The MAA definition of 'Cause' is "the event that led directly to the accident".
2. In my view, the 'accident' was the death of the pilot. He should have survived this ejection - the MAA report says so. Had he survived, this would not have been an accident, probably only an incident.
3. In my view, the 'event' that led directly to the pilot's death was the failure of the drogue shackle to operate correctly. Not, in my view, the inadvertent operation of the seat pan handle.

The reason I have contributed to this thread is the way the report treats the content and application of RTI/Hawk/59. It's my view that had this RTI not been issued in the form it was, the pilot would have survived. Despite the MoD having no safety case for the seat (required to validate the RTI), despite there apparently being no records of how 2 PTs, 22 Gp, 1710 NAS, MB and others discussed and decided on the RTI, the MAA assessed all this as merely an 'other factor'. From my own experience, i cannot understand how anyone would not recognise the significant safety risks posed by dismantling a vital part of the ejection seat every 50 flying hours. I honestly fail to understand why the MAA did not pick up on this as a major contributory factor.

However, the case is now going to proceed, and for my part, I intend to make this my final post on this thread until the verdict is in. Thank you to all those who have replied to my posts with such thoughtfulness and honesty.

I would finish by expressing my sincerest condolences to Flt Lt's Cunningham's family and friends.

Best Regards as ever to all those who serve their country,

Engines

NutLoose

28th Sep 2016, 18:52

i cannot understand how anyone would not recognise the significant safety risks posed by dismantling a vital part of the ejection seat every 50 flying hours. I honestly fail to understand why the MAA did not pick up on this as a major contributory factor.

Totally agree with you, it reminds me of the Pipers that had a Spar failure, they then decided you would need to inspect the bolt holes every I think 100 hours, it was found they were doing more damage to the spars of the fleet pulling bolts out that would normally never be removed, than the odd case of failure. So it was cancelled.

oldmansquipper

29th Sep 2016, 13:52

Nutloose. In a lighter vein - Very similar to the Tucano QRB cover plate over rotation issue late 90s?. Because the Quick Release Box was fitted `to the seat`as part of the SCH when in the aircraft, Weapons Techs (the plumbers) developed an `Instruction` (SI?) to check for over rotation on AF/BF. This consisted of instructions to "Try to turn the cover plate beyond the stop point...." Results? from 1 or 2 arising the failure rate (and u/s QRBs/Aircraft) increased rapidly until someone called off the gorillas!

"A I`m an armourer, B I`m an armourer...C etc. "

PDR1

29th Sep 2016, 15:06

...the difference between armourers and bombs being that you can actually get *smart* bombs...

:E

PDR

superplum

29th Sep 2016, 15:58

Top West 50

29th Sep 2016, 16:00

Before I comment, I must declare an interest. Tomorrow, on 30 September, I will celebrate the 52nd anniversary of becoming the 664th pilot to save their life using a Martin Baker ejection seat. A year or so later, I attended a gala dinner at The Dorchester after Martin-Baker notched up their 1000th success. Not a single ejection, within the design limits of the seat had been unsuccessful. Subsequently, several thousand more, 7506 precisely, are here today because of the brilliance of Martin-Baker engineering. Writing to me in October 1964, Sir James Martin, Managing Director and Chief Designer said “as the person responsible for the design of all our various ejection seats, it naturally causes me great pleasure (to hear about your escape).” At the same time, Sir James extended a “hearty” invitation to have lunch and visit the works. It took me until the 50th anniversary year, 2014, to accept the invitation. Meantime, for the rest of my flying career, I happily entrusted my survival to Martin Baker seats. It is vital not to underestimate the psychological effect of knowing that you were flying with the world’s best and most reliable escape apparatus. Put simply, Martin Baker was a benchmark for engineering excellence and reliability. Visiting the factory in September 2014, it was impossible not to be impressed by the sheer dedication and attention to detail in every aspect of their Denham factory.

During my RAF career of nearly 35 years, I had the duty to investigate 2 high-profile aircraft accidents, one of which resulted in the death of 9 crew members, so I am fairly well acquainted with the investigation process and most of the other human consequences that such investigations inevitably yield. The aim of the accident investigation is to determine the cause and much mental effort is devoted to isolating the root cause of the accident from other factors which merely contributed to the accident. I expect that this inquiry team, together with its convening authority, would have been presented with a similar challenge. The trouble with aircraft accidents is that they often result from a sequence of events, none of which, in isolation would necessarily have caused the accident. The day that “Murphy’s Law” strikes the sequence of events, design failure, technical failure, maintenance error, human error etc, has been allowed to continue to a conclusion. It follows that, quite often, humans can spot things before they go wrong, interrupting the fatal chain before catastrophe strikes. Often, humans are unaware of the dangerous turn of events and so they do nothing. Very rarely, humans disregard the warning signs that their expertise and training should have equipped them to see. In this case, the inquiry will determine whether any personnel had been “negligent” and whether they should be held to blame for their action or inaction. Proving negligence is not straightforward for the living and, at least in my day, almost impossible for the deceased. Often, in the absence of categorical proof, sleeping dogs must be left to lie. This doesn’t, however, prevent lessons from being learned and procedures to prevent recurrence being enforced. Hopefully, before all this occurs, risk assessments will have identified most, but crucially never “all,” of what could go wrong.

I do not know very much about the “Military Aviation Authority” since this tri-service organisation replaced the Inspectorate of Flight Safety which used to be responsible for accident investigations in my day but I do not suppose that the principles of investigation are very much different. I am certain there will have been a meticulous inquiry in this case.

It is therefore somewhat surprising that the Health and Safety Executive should consider that military business falls within their judicial terms of reference. More fundamentally, I wonder what possible public interest there could be in rehearsing a very expensive inquiry and then failing to get a conviction (for fail they surely will for the reasons I have outlined above)? Quite what washing dirty laundry in public will do for morale is very hard to see and undermining the perceived integrity of life-saving systems in such a public way is surely not a sensible thing to do. If it is Flight Lieutenant Cunningham’s kin who are driving the prosecution, I hope they get what they want but I have to say, as one who is married to the widow of a victim of a notorious bit of flying and engineering negligence, I would have advised differently.

The court case will be expensive, time consuming and will, regardless of the result, undermine confidence in the good order and discipline of the service. It is unlikely to expose anything more of relevance that has not already been uncovered by the Inquiry.
For those of us who are dismayed (and very frightened) by the remorseless erosion of defence capability in recent years, it beggars belief that scarce human and financial resources should be diverted from our fighting posture.

superplum

29th Sep 2016, 16:02

...the difference between armourers and bombs being that you can actually get *smart* bombs...

:E

PDR
More useful than smart4rses!

:)

PDR1

29th Sep 2016, 16:14

Oh absolutely, no offence intended - just a target of opportunity as they say.

:E

PDR

PDR1

29th Sep 2016, 16:16

I could get to "E"

With or without referring to the AP...?

:E

PDR

Easy Street

29th Sep 2016, 19:55

Further reflection on the drogue shackle bolt issue leads me to ask this of the airworthiness and safety experts here. Was it sufficient for MB to deal with the known potential for shackle pinching by issuing maintenance guidance alone, and not doing anything more fundamental (such as introducing a shouldered bolt, reshaping the components, or even issuing a torque setting) to mitigate the issue? If it could be shown that a comparatively simple physical modification would have removed the accident mechanism, then would MB be open to a charge of negligence for not having taken such action in the 20-odd years between the risk becoming known and Sean's death?

EAP86

29th Sep 2016, 19:59

TW50, agree it's odd to see the HSE becoming so prominent at military aircraft accident sites, not that they have a perfect right to be there, but they do seem to turn up quite often these days. I think that Scampton turned out to be a bit of a perfect storm with the MAIB, Police and HSE all appearing (with the Coroner pulling some of the strings too). Does it need all of them? Does it really help the efficiency of the process especially when other aircrew could also be at risk from a technical fault?

I know that the AAIB have negotiated a national agreement with the 43 UK Police forces on protocols for aircraft accidents, surely something similar could be sorted out for military accidents? Whatever happens, it's still a bit odd that the HSE feel they need equal billing in all circumstances. Maybe this is part of their motivation?

EAP

glad rag

29th Sep 2016, 23:44

I could get to "E"
Shirley that should be "F" ?

tucumseh

30th Sep 2016, 04:00

Easy Street

Was it sufficient for MB to deal with the known potential for shackle pinching by issuing maintenance guidance alone, and not doing anything more fundamental (such as introducing a shouldered bolt, reshaping the components, or even issuing a torque setting) to mitigate the issue? If it could be shown that a comparatively simple physical modification would have removed the accident mechanism, then would MB be open to a charge of negligence for not having taken such action in the 20-odd years between the risk becoming known and Sean's death?I’m afraid the answer is not simple. The contractual relationship, if any, between MoD and Martin Baker needs to be known. MoD is obliged to put in place a continuous contract to maintain the build standard (which is what you’re talking about). This hasn’t been policy since at least June 1993 and it was fragmented for a few years before that. A key part of that contract is the delegation of financial powers to a named individual at the company, authorising him to self-task safety tasks, in the certain knowledge the company will be paid. The aim, of course, is to get crucial information out there as soon as possible. If there is no contract, there will be no task, and today 99.999% of MoD staff will give you a blank look when you mention this.

I’m not convinced MB did not provide the technical information/advice to MoD. This aspect has not been investigated at all and a key event was MoD shutting down its central registry and agency contracts that dealt with all such documentation. At a stroke, it meant that the process was no longer managed as a full-time job by a few, but as a 5 minutes, once a month task by hundreds. Without training. We got a few days notice of these changes and a party of us descended on the old registry to retrieve files before they were destroyed, only to find no sign of life, or filing cabinets. And no instruction was issued to companies telling them of any new department or address.

The same contract is the vehicle for maintaining the Safety Case. The Mk10 ejection seat didn’t have one, which points to a breakdown in this contractual relationship, as well as serial offences by MoD staff, who MUST have made false declarations in airworthiness documentation. (The HSE knows this, and says there is nothing wrong with it. I disagree).

One could say there is a moral obligation on the company, but an oft-asked, and never answered question was – how long must they be expected to work without payment? For example, MoD is obliged to provide Sample (or “Hack”) equipment, and often specialist test equipment, to companies under the above contract; and pay for their maintenance. As a matter of policy, AMSO started to run this down in 1990. I well recall that on the day Maggie Thatcher stepped down, I was at one company (Thorn-EMI Varian) and they handed an AMSO supply officer a letter asking which car park the MoD wanted over £2M worth of its test equipment dumped in. (Environmental Test Chambers, which had been rotting for over 2 years without maintenance). They were fed up subsidising MoD, and paying rent for storage. That TE was urgently required for Merlin development.

As to this specific case, I cannot say if the actions you suggest should have been a modification (or a Change), but your are right – either way one would expect Martin Baker to make a proposal to MoD. Who is to say they didn’t? Again, it became routine in 1990/1 for such suggestions to be ignored, because AMSO were just beginning to implement the policy of running down airworthiness management. One of the first instructions was not to amend APs. Alternatively, Martin Baker may have noticed the potential problem, but decided it was a procedural or maintenance oversight. After all, a maintainer should be expected to realise something is wrong if he’s tightening a nut and starts cutting thread on the shank of a bolt. Also, if trained on the mechanism, he should know it has to be free to move/swivel when assembled, and that a simple check of this is required. Martin Baker could, legitimately, claim that only an idiot would cut new thread and tighten it so much as to render it unfit for purpose. Part of the process is training and proper application. It is not for Martin Baker to stand over the maintainer and check his work. And, in any case, Martin Baker should be immediately absolved of any liability because of the illegal 50 hour RTI. The very fact this was implemented indicates either (a) there was no contract, or (b) specialist advice was ignored. Those familiar with the Mull of Kintyre case will see the resonance here. Odiham issued an illegal Servicing Instruction, probably because a request to have the design made safe was turned down. MoD has form here – Martin Baker does not.

Chugalug2

30th Sep 2016, 07:09

tuc:-
...serial offences by MoD staff, who MUST have made false declarations in airworthiness documentation. (The HSE knows this, and says there is nothing wrong with it. I disagree).

Then HSE will learn a very valuable lesson if they discover their mistake in court. In which case might we then expect them to issue a Crown Censure against the MOD? We live in interesting times...

EAP86

30th Sep 2016, 07:35

"authorising him to self-task safety tasks"

I'm aware of at least one example where a PT officer seeing this scrubbed the item out of the contract saying that only a crown servant could authorise expenditure no matter how small the limit of liability. In effect the amount was just enough to decide whether any more effort would be required for further investigation.

Was it Def Stan 05-125 which contained this? I'm also aware of a discussion at NETMA about monitoring safety and airworthiness where the PT said "...but we do this". I can't help thinking that vague or misleading regulations contributed to the confusion. Possibly a mitigating factor in MBA's case?

EAP

RetiredBA/BY

30th Sep 2016, 08:30

I have no idea of the procurement process but as a long time, 12 year, occupier of MB seats, and an ejectee myself. ( Mk 4 seat) I read most of the MAA report with more than passing interest.

The thing that struck me as very strange indeed is that installing the safety pin was part of the after landing checks and it was sometimes, often, done by feel !

In my day we did not install the pins until the aircraft was parked on the line, dispersal, and the the pins, seats and canopy, very carefully replaced.

Was there some reason why the RAF changed, or even allowed, these procedures as the report said?

H Peacock

30th Sep 2016, 08:56

NutLoose

30th Sep 2016, 09:08

It makes you wonder what the MOD support contract was that was in place, for the aircraft I maintain you pay for the manuals and all updates, service bulletins etc, the only things you do not need to pay for are Airworthiness Directives which come from the CAA, FAA etc.
I do wonder if the contract was all embracing, that could account for the RAF not getting some of the documentation other forces appear to have received.

Civi street wise we always replace lock nuts with new, RAF wise we used to check for run down torque resistance, you can measure that on a torque wrench..

As for a shouldered bolt, there might have been good reasons, such as the reduced diameter threaded portion if the bolt was shouldered not being of sufficient strength so as to not fail in the case of an ejection, and the main shank of the bolt not having sufficient clearance in the shackle for its diameter to be increased.

.

H Peacock

30th Sep 2016, 09:29

As for a shouldered bolt, there might have been good reasons, such as the reduced diameter threaded portion if the bolt was shouldered not being of sufficient strength so as to not fail in the case of an ejection, and the main shank of the bolt not having sufficient clearance in the shackle for its diameter to be increased.

Umm, possibly, but there must be a better design! If not, why not use an appropriate 'feeler gauge' type tool to place between the inside of the shackle and the scissor linkage to tighten the nut against that is removed once the nut has been correctly torqued.

Having spent many hours sat on both Mk3 and Mk 4 seats, the face-screen pin was always inserted 'blind'. Quite a test of dexterity, flexible limbs and a long reach! I recall in the JP when dual we did each other's pin.

The seat pin was also fitted blind, but then both pins visually checked upon leaving the aircraft.

superplum

30th Sep 2016, 09:44

Shirley that should be "F" ?
That was it - I knew I was close!

:O!

superplum

30th Sep 2016, 09:56

......As for a shouldered bolt, there might have been good reasons, such as the reduced diameter threaded portion if the bolt was shouldered not being of sufficient strength so as to not fail in the case of an ejection, and the main shank of the bolt not having sufficient clearance in the shackle for its diameter to be increased.

.

Nope. the shouldered bolt design had been in use for decades. My first encounter was in 1963 on JP Mk4 seats. Their use continued at least to Mk 9. Ejection forces would have negligible (if any) effect on the bolt which only serves to hold the drogues (same sizes) attached until the aircrew/seat separate.

Davef68

30th Sep 2016, 10:37

Just a thought, is this case now sub judice?

NutLoose

30th Sep 2016, 10:45

Nope. the shouldered bolt design had been in use for decades. My first encounter was in 1963 on JP Mk4 seats. Their use continued at least to Mk 9. Ejection forces would have negligible (if any) effect on the bolt which only serves to hold the drogues (same sizes) attached until the aircrew/seat separate. But the seat is designed for various types, perhaps the shouldered bolt previously used had reached its design limits on the later seats, seat weight, crew weight, ejection envelopes etc all will play their part. There could be a myriad of reasons to redesign it, and there must have been some, otherwise they wouldn't have gone to the expense and trouble of doing so, and by removing the waisted portion, one would have thought strength of the bolt was possibly one of them..

PhilipG

30th Sep 2016, 10:51

I do wonder if the contract was all embracing, that could account for the RAF not getting some of the documentation other forces appear to have received.

There are two things that come to my mind here: -

We are informed that other users had been informed many years previously about this problem. What was the process for informing them? Was SIL 704 a reissue of a previous communication, that the MOD/RAF had not noticed that it had not got?

What was the advice to the other users of the Mk10 seat and if this advice had been implemented by the RAF would this event have occurred? The other side of this question is did the advice to users required new parts to be put into the seats? If so, from a corporate governance point of view, how is it that MB did not notice that the MOD/RAF had not ordered any of these kits..

squawking 7700

30th Sep 2016, 11:12

There's a third point to add - it's apparent that a number of people in the UK knew/know of the issues and I'd guess that more than one person who works/has worked on those seats, knows of the issues - why wasn't this alerted/raised back through a process to make safe the design?

dctyke

30th Sep 2016, 12:02

Getting a bit more into the technical aspect of the shackle and bolt. I agree that, as stated early, It's very surprising that MB didn't design a bolt with a shoulder that the nut was tightened up against. I've been a dreadful aviation hoarder/scavenger for years and have played with plenty of MB products. The innovative design and build quality is staggeringly impressive. So the use of a 'normal' off the shelf bolt is very surprising. (I know MB probably made the bolt specifically.

I am slightly puzzled about the torquing up of a locknut & bolt where you don't want the nut to bottom-out on the thread or even against a fitting the bolt goes through. In other words you are purely relying on the resistance to the 'locking' ability of the nut. A brand new nut is invariably going to be stiffer than a well worn one. How do you calculate a torque that caters for both cases? Clearly, if a normal nut were used you could only achieve a tightening torque when the nut is up against the fitting! If the specified tightening torque is less than the resistance of a worn nut screwed along a continuous thread, then you can only achieve that value when the nut impinges on something else.

Although I have said it already I'll say again. That bolt was never meant to be fastened/unfastened all the time. For the Ist half (or more) of that seats life it's possible it was never undone. Work would only have been ever done in the seat bay and opening the shackle was done by releasing the BTRU. I would be interested to know who authorised 1st line rectification of ejection seats after the demise of seat bays. I would like to think this would have been discussed at MB and recorded decisions made.

Edit, a distant memory but I'm sure at servicing we tested the opening of the shackle we a spring balance measurement, had to be under a certain pull weight.

tucumseh

30th Sep 2016, 12:53

EAP86

I'm aware of at least one example where a PT officer seeing this scrubbed the item out of the contract saying that only a crown servant could authorise expenditure no matter how small the limit of liability. In effect the amount was just enough to decide whether any more effort would be required for further investigation.

Was it Def Stan 05-125 which contained this? I'm also aware of a discussion at NETMA about monitoring safety and airworthiness where the PT said "...but we do this". I can't help thinking that vague or misleading regulations contributed to the confusion. Possibly a mitigating factor in MBA's case?

The PT officer obviously didn't know that the Def Stan was mandated in every aviation related contract. This delegation to Post Design Services Officers at Design Authorities is unique, and it was why MoD Technical Agencies (uniquely) are named in contracts, whereas otherwise it is simply the post title. The PT officer you mention almost certainly wasn't a properly authorised or qualified TA. He may have been "Suitably Qualified and Experienced" as defined by the MAA, but I can assure you this comes nowhere near the criteria for a TA, who (typically) will have worked on similar kit as a fitter/technician/ diag/supervisor, then been a design draughtsman or similar, engineering staff officer in an HQ branch, promoted into MoD(PE) and been manager of scores of projects. Only then would you be considered. However, I concede this has probably been diluted since my day!

Locknuts - 100% replacement. Given there are arguments for and against re-use, it is better to be safe than sorry, for the sake of a few pence. As a young planner/examiner, I'd have been crucified if I didn't specify new nuts every time. But at front line, I accept a concession might be occasionally necessary. I always thought of this in the same way as in-line splices, being a simple greenie.

NutLoose

30th Sep 2016, 13:35

Lock nuts in the RAF while I was serving were not mandatory to replace, you checked their run down torque, and were trained to do that, however I always did replace them and have ever since, I once had a cost conscious owner question me over it, I said I was replacing them end off, he then brought in a magazine article a few weeks later that had a rudder bar that came adrift because of it and the penny finally dropped.

tucumseh

30th Sep 2016, 13:48

I always did replace them

I recall a fitter trying to get away with old ones on a generator, which exploded during its heat run as the end plate came loose. Armature went through a double skin wall into the battery shop, which was luckily empty. Also, luckily, heat runs were in a dedicated room, and you weren't allowed in it during the run. He'd have been shredded.

pulse1

30th Sep 2016, 14:16

Just digressing a little:

NTSB: High speed, worn parts led to deadly Reno Air Races crash - CNN.com (http://edition.cnn.com/2012/08/27/us/nevada-air-race-probe/)

" the main culprits, according to the NTSB, were several lock nuts on the left trim tab - a aerodynamic surface on the horizontal part of the plane's tail, nuts that had not been replaced for at least 26 years".

falcon900

30th Sep 2016, 15:50

An aspect of this tragedy which seem to have attracted few comments is the fact that the chain of events which led to the accidental activation of the seat began as a result of the aircraft being flown with one of the groin straps through the seat pan firing handle. Given the consequences in the event of an ejection, it is to be hoped that this is a highly unusual occurrence, but coupled with the ease with which the safety pin can be fitted incorrectly, it would place quite a premium on much greater care around entry and exit procedures.

NutLoose

30th Sep 2016, 17:45

Yes pulse they were nylocks

http://www.ntsb.gov/investigations/AccidentReports/Pages/AAB1201.aspx

Totally agree Falcon, but it is the nature of the beast that to save lives there unfortunately the design has risks involved. As for greater awareness I agree again, though unfortunately as in all things, familiarity can and does breed complacency.
It has been a long time since I worked on them, but I seem to remember the L39 also had switches in the in the nosebay that would disarm the seats and make them safe as a back up to the normal seat safety features, OK unless they forget to be set to them to armed that is.

Flight_Idle

30th Sep 2016, 19:11

It surely should be evident that one should not 'Pinch' fork ends, or similar structures where freedom of movement is critical. Shouldered bolts being the norm to prevent this, however if not possible, the 'Feeler gauge gap' being blindingly obvious.

I was not an armourer, many other critical bolts on aircraft though.

The very complex 'Top down' management seems to think that the guy on the 'Coal face' should be dismissed if they have concerns.

I remember pilots checking for a loose fit on the shackle, basic stuff really & not really all this 'Enormous paper work trail' that people talk about.

Just an ex liney, take that for what you will.

Easy Street

30th Sep 2016, 22:36

An aspect of this tragedy which seem to have attracted few comments... would place quite a premium on much greater care around entry and exit procedures.

If you haven't already read the section of the SI report which covers unit culture, I recommend you do as it goes into detail on the very issues you mention. The section also left me with the impression that there would have been a lot more to say had the scope of the investigation been any wider.

tucumseh

1st Oct 2016, 05:43

I remember pilots checking for a loose fit on the shackle, basic stuff really

I can't, and so never, comment on what pilots should or shouldn't do, but this seems sensible. What I would say is it should have been the umpteenth time it was checked. As East Street says, there is a cultural aspect to this which the SI report is remarkably frank about, even though elsewhere it fails to properly assess events and factors. This makes it all the more puzzling why the HSE are going after Martin Baker.

But the "enormous paper trail" is what allows you to identify where the breakdown took place. The Secretary of State also requires it before allowing the aircraft to be flown. There has clearly been multiple breakdowns and that should concern everyone, because the system is designed to withstand failures (checks, double checks, defences in depth). THAT is where senior staff never allow inquiries to go.

falcon900

1st Oct 2016, 11:15

Thanks Easy Street. I have read the SI report, and was struck that I have read similar comments about unit culture in more than one contemporary SI report, which is another strand of concern, but what I was getting at with my original post is that whilst there is much discussion on here of the shackle/bolt aspect, and the contractual/safety case aspect, the fact that an experienced pilot can go flying with a crotch strap through the ejector handle is astonishing to the casual observer, and yet seems to have passed on this forum more or less without comment.
I am also struck that the issue of the safety pin being inserted with the handle in an unsafe position seems to be presented in the SI as new news. Call me cynical, but are we asked to believe that in the many thousands of Hawk operating cycles, this has never happened before, or has, but was never noticed? Given the location of the pin, it seems obvious that the pilot would find it difficult to spot the error, but ground crew are in a much better position to do so, and I find it hard to believe there were not instances in the past when they did.

212man

1st Oct 2016, 11:20

1. The MAA definition of 'Cause' is "the event that led directly to the accident".
2. In my view, the 'accident' was the death of the pilot. He should have survived this ejection - the MAA report says so. Had he survived, this would not have been an accident, probably only an incident.
3. In my view, the 'event' that led directly to the pilot's death was the failure of the drogue shackle to operate correctly. Not, in my view, the inadvertent operation of the seat pan handle.

I don't think stands rigorous scrutiny. If I drive off the road into a tree and my seatbelt was incorrectly attached to the car structure, allowing me to be thrown through the windscreen and at the tree, then:

1) The cause of the accident will be whatever precipitated my departure from the road
2) The cause of death will be 'blunt force trauma' after hitting the tree, and
3) A contributory factor (to death) will be the failure of the seatbelt to perform its designed function due to incorrect installation

Surely that analogy holds for this tragic case?

SirPeterHardingsLovechild

1st Oct 2016, 13:13

Hurrah! 212man

Welcome to the small club. Me, you (and the MAA)

Good analogy, although someone will be along shortly...

dervish

1st Oct 2016, 13:53

I'll defer to experts but the obvious difference is that in the hawk there is a device that is meant to prevent the blunt force trauma after you exit the windscreen. And does there have to be a single "event"? And does this matter when some clown signed off the release with no safety case? Over to the MAA to say how this was missed ........

glad rag

1st Oct 2016, 14:13

The reality is that the RAF operated this aircraft/ejection seat combination for nearly 40 years before the accident occurred, and during that time there were successful ejections from RAF Hawks, so it seems unlikely that the failings were due to unfamiliarity or design flaws. Somewhere along those years personnel 'lost' their full understanding of operational and maintenance procedures. When, or if, changes were introduced processes should have been in place to review and understand revisions so that any re-training was effective and new requirements were safely applied.

Spot on.
I did ask about the mod state of the "fleet" but the answer was vaguely close to maybe so was both meaningless and annoyingly insubstantial, on the topic of nuts and bolts the snco plumber commented that the DAP says "tighten" and as far as he would be concerned that meant "tighten" properly.

So there's your proof, technical ability reduced to lowest common denominator on the alter of budget reduction.

NutLoose

1st Oct 2016, 14:14

But Dervish, that is assuming they knew there was a problem before the incident, surely they can only be culpable if they did.

On the topic of nuts and bolts the snco plumber commented that the DAP says "tighten" and as far as he would be concerned that meant "tighten" properly.

Precisely, the term tighten means you would run the nut down the bolt until resistance is felt, you would not tighten a bolt and stop short of the shackle or short of when the nut becomes thread bound, the failing is in the terminology of what is required.

Everyone keeps mentioning shouldered bolts or introducing feeler gauges as the solution, well as we have discussed a shouldered bolt may or may not have strength or clearance issues, the simplest solution would have been to replace the existing bolt with one with a longer shank, thus retaining the diameter ( and strength ) of the current item but making it impossible to over tighten the nut or pinch the shackle by the simple fact the nut will become threadbound before it reaches that point.

..

dervish

1st Oct 2016, 15:29

The MAA were around for 20 months before the accident and claimed it had all the PTs audited. Even if they used a tickbox sheet, surely the cross in the box would fail the PT?

Chugalug2

1st Oct 2016, 17:58

We went through all the RTA analogies on the Mull thread (usually to support the MOD/RAF/RO's finding of pilot Gross Negligence) and look how that turned out. As in that case this outcome will be determined elsewhere.

MBA are simply the latest scapegoats for the Gross Negligence of certain RAF VSOs and the cover up of that by other RAF VSOs. At the moment the HSE would appear to need convincing of that, so perhaps MBA should convince someone else, then they could convince HSE...

Meanwhile the usual stove piping will continue, no doubt.

Onceapilot

1st Oct 2016, 18:36

Having flown over 1,500 hours on the MB Mk10 seat, I am surprised that the essential function of the scissor shackle was so essentially flawed! :oh:

OAP

tucumseh

2nd Oct 2016, 07:54

The Service Inquiry only states the servicing information, from 1991, could not be found. At the Inquest, this morphed into “Was not provided by Martin Baker”; yet no evidence was presented either way. I'd be surprised if the HSE and Martin Baker had not spotted this hole in the evidence trail. So, either this does not relate to the charge, or the hole has somehow been filled in. If the latter, why have we not heard of it, for example via a reconvened SI?

I say again, something is going on here. This case shares many similarities with the likes of Chinook, Nimrod, Hercules, etc. (systemic failings) but in those cases the HSE refused to get involved and MoD was permitted to judge its own case (and still is). This time the end game is very different. Now, MoD is (or should be) a witness in court of law, which it will find more difficult to influence. I can't imagine it is happy.

AtomKraft

2nd Oct 2016, 08:26

Surely, if M-B had known that the RAF would be undoing and retightening that bolt so often, they'd have taken a simple engineering step to prevent the shackle being pinched?

They probably thought that this piece would remain untouched- like a great many assemblies on their seats- throughout the life of the seat. And if anybody WAS going to mess with it, it would be in a seat shop or at their factory.

Tinribs

2nd Oct 2016, 17:34

It is some years now but!

As I recall with the Mk 10 seat if the seat pan handle was slightly dislodged it was possible to insert the pin through the seat aperture passing not through but under the handle leaving the handle free to operate

Maybe that got fixed with the arrival of the new larger floppy handles

tucumseh

2nd Oct 2016, 17:43

Surely, if M-B had known that the RAF would be undoing and retightening that bolt so often, they'd have taken a simple engineering step to prevent the shackle being pinched?This undoing/retightening was carried out as part of a Routine Technical Instruction, issued by MoD.
An RTI is only permitted if the Design Authorities (Martin Baker and BAeS) do not need to be involved in any way whatsoever. A 50 hourly regime on a safety critical escape system most definitely does not fall into this category. Therefore, it is unlikely Martin Baker knew of the RTI, or if they did know they were excluded from the process. As I mentioned before, this has resonance with the illegal Servicing Instruction issued by Odiham on Chinook HC Mk2 and was in all likelihood considered necessary by one part of MoD because another part had cut funding, thus preventing Martin Baker being involved.

If any action connected with this RTI forms part of the HSE's case, then all Martin Baker need do is table the RTI and demand that the signatory be a witness, to explain himself.

Brian W May

2nd Oct 2016, 18:10

Tinribs: Until this accident it still was (I was told). When I left BAE, lots of steps were being made to address this issue too.

A lot of time and effort were finally being applied to this problem which was well known (a tad late in my opinion).

Sadly, most of us who have been/are in the industry (civil or military) could probably point at other 'known' issues - Haddon-Cave all over again.

Sad too that it takes a body count. There are no winners - except perhaps the bean-counters (in the short term).

Chugalug2

2nd Oct 2016, 21:35

BWM:-
There are no winners - except perhaps the bean-counters (in the short term).

Never was a truer word spoken. This sorry mess was initiated in 1987 when a disastrous short term AMSO policy led directly to the plundering of the previously ring fenced Air Safety budgets. Once started the pillage had to continue. Those who would not obey illegal orders to suborn the regulations had to be got rid of, and with them went the accumulated knowledge and experience of decades. Those engineers were replaced by administrators and soon the corporate memory was wiped completely clean.

Airworthiness is a continuous process. Interrupt it, ignore it, pay lip service to it, and the results are inevitable. 63 lives lost in airworthiness related fatal military air accidents in PPRuNe featured threads alone. MOD's efforts to pin the blame on aircrew, on senior officers, and now on companies, are its desperate attempts to obscure the truth, that all this was caused by the Gross Negligence of certain RAF VSO's, and then covered up by other succeeding RAF VSO's. Quite apart from the price paid in blood and treasure they have dishonoured the Service which has promoted them to such august ranks.

This has to stop. There must be an end to these avoidable tragedies. The MAA and MilAAIB must be made independent of the MOD, and of each other, and the long and painful reform of UK Military Airworthiness set in motion.

Let right be done!

overstress

3rd Oct 2016, 00:34

the fact that an experienced pilot can go flying with a crotch strap through the ejector handle is astonishing to the casual observer, and yet seems to have passed on this forum more or less without comment.
I am also struck that the issue of the safety pin being inserted with the handle in an unsafe position seems to be presented in the SI as new news. Call me cynical, but are we asked to believe that in the many thousands of Hawk operating cycles, this has never happened before, or has, but was never noticed?

I was shown this 'gotcha' by the tech instructor when I did Hawk ground school in 1986...

longer ron

3rd Oct 2016, 07:28

Call me cynical, but are we asked to believe that in the many thousands of Hawk operating cycles, this has never happened before, or has, but was never noticed? Given the location of the pin, it seems obvious that the pilot would find it difficult to spot the error, but ground crew are in a much better position to do so, and I find it hard to believe there were not instances in the past when they did.

Yes it had happened before,groundcrew were re briefed after each incident but please take into account that the Reds did not normally use cockpit access steps when away from home,it would be unsafe to assume they had cockpit access steps in use during the subject sorties (anybody know for sure ?)- if cockpit access steps not in use then the groundcrew would not be able to see the SPH area anyway !

Easy Street

3rd Oct 2016, 09:28

longer ron: The Reds do use steps at Scampton; see pic below from the BBC news article reporting Sean's death. Anyway are you suggesting that it is not possible to check whether the seat pin is inserted unless steps are used? I beg to differ - you just need to climb the integral steps and peer over the edge of the cockpit. Otherwise how would anyone (aircrew included) check the seat was safe before standing on it to conduct the rest of the pre-flight checks?

http://ichef.bbci.co.uk/news/624/media/images/72181000/jpg/_72181508_72181507.jpg

longer ron

3rd Oct 2016, 09:43

Would be difficult for groundcrew to do a proper check of the SPH from the built in step,the Hawk front seat SPH area is cramped by the Windscreen Arch for a vertical visual check and not sure if that was SOP with the Reds at that time.
Your photo is not conclusive proof that Aircraft Steps were used during the accident a/c start - which is why I asked my question !

longer ron

3rd Oct 2016, 10:06

Just had a look at the Accident Report narrative and it does indeed look like steps were available at Scampton.

http://i695.photobucket.com/albums/vv316/volvosmoker/scampton_zpswrkbl2qd.jpg

longer ron

3rd Oct 2016, 10:33

I did not really want to get involved in this subject again but I would just say that the technical investigation of this accident was first class and anybody posting on this thread should really read the full report(s) prior to posting.
I would also agree with some previous posters that it had been standard practice for aircrew to 'rattle' the scissors shackle during seat checks right from early days on the Hawk - so the potential problem with the shackle was well known about !

Tinribs

3rd Oct 2016, 16:54

I was the Maint TP at the Canberra MU, I knew the shackle should be slack ,because they said so, many times; but I never understood why.

If I did not know with several tours done on many seats then who would?

I suppose over the years if the significance of an act is not understood then attention to that action will slide

Distant Voice

10th Oct 2016, 09:19

Does anyone know if a similar RTI to RTI/Hawk/59 was ever raised for the Mk10 seat fitted to the Tornado? I know that the Tornado's seat has a gas shackle and not a scissor shackle, but the RTI referes to the cross beam which I believe is common to both types of seat.

DV

tucumseh

10th Oct 2016, 09:48

I suppose over the years if the significance of an act is not understood then attention to that action will slide

This is a key observation, both in this case and in general. Many Tech Pubs are written on the premise that the target audience is fully trained, to a stated level. Much is assumed. If you stop funding training, or start recruiting people who have skipped 5 grades, then serious funding is required to re-write the ATPs for the new target audience. This was notified, to my knowledge, in about 1991, promptly followed by a nearly 30% cut in funding and an instruction to stop ATP amendments.

Ogre

10th Oct 2016, 09:52

I'll just chuck in a point for discussion, I've only skimmed across the first few pages so I may have missed some bits:

The ALARP (As Low As Reasonably Practical) principle has been the corner stone of safety engineering for decades. The basic outline has been described as the application of more and more mitigations until you reach a point where further mitigation was unjustified on the grounds that implementing the mitigation would not reduce the risk further.

In crude terms, you add more and more mitigations until you reach a point where the risk is acceptable.

ALARP has been replaced with SFAIRP (So Far As Is Reasonably Practicable) sometimes referred to as SFARP. With SFARP the intent is that you start with a list of everything you could do, then discount or remove those mitigations that are not reasonably practicable to implement.

In theory ALARP and SFARP should arrive at the same point, but there is very little significant case law currently available to draw a conclusion. However there are some opinions that you are less likely to be able to prove that you have met SFARP than ALARP, because in the event of being taken to court you (as the defendant) would have to prove that you have indeed considered everything "practicable" and either implemented it or justified why it was not SFARP.

It may be that in this case the HSE are considering that MB did not meet SFARP by not doing everything reasonably practicable, including consulting, communicating and cooperating wit their customers.

tucumseh

10th Oct 2016, 11:53

not reasonably practicable to implementOne problem becomes obvious. The blurring of what is and isn't practicable caused by arbitrary, and quite draconian, cuts to safety related funding. "Practicable" gets overtaken with "don't do it" and "waste of money". Same applies to manning safety/risk related posts. In the Nimrod Review, much was made by Haddon-Cave of the performance of the Safety Manager, who was parachuted into a job he was untrained for, without any superiors who had the slightest clue. That is not their fault; it was, and remains, an organisational fault. But what Haddon-Cave omitted to say or comment on was the (to MoD staff) astonishing fact that the DLO Nimrod IPT had actually been allocated a Safety Manager in the first place. In this period (early 00s) our 2 Star in DPA (Chinook, Nimrod, etc) flatly refused to allocate safety or risk related posts. There was no pretence. Not required. Waste of time and money. Functionally unsafe aircraft can be delivered - just sign to say they're ok.

In this case, even though I've never had dealings with Martin Baker, I find it impossible to conceive of them not fulfilling their contractual obligations. But, while the MoD may have been a customer, how quickly and to what extent does that obligation recede if you're no longer under proper contract? How long do you wait without income before making staff redundant? If or when a contract appears, how long does it take to recruit and retrain staff, and do you still retain corporate memory? Where are the MoD staff whose job it is to monitor and manage this situation? The MoD(PE) section who did this (on avionics) was disbanded in June 1993, after 3 consecutive years of 28% cuts. Within 12 months major contractors, with a better cash flow than Martin Baker, were laying off staff and warning MoD of huge start-up costs should it ever want more work done. Some beancounter would hoover up gongs and awards for reducing in-year expenditure, while everyone else was preparing for a huge bow-wave and financial black hole. My concern today is that Martin Baker don't retain sufficient knowledge to defend themselves.

EAP86

10th Oct 2016, 14:47

Ogre, just to clarify. As I understand it, the Health And Safety At Work Act is written using the "so far as is reasonably practicable" form of words. "As low as reasonably practicable" is the HSE (and safety engineering) preferred translation of the act wording into something a bit more meaningful for engineers. One has not replaced the other.

Additionally the ALARP concept requires that further mitigations are required until the 'cost' is grossly disproportionate to the risk reduction gained. Typically this means that a Court would expect that the cost of further mitigations would be a factor of 3 to 10 times more than the risk reduction (expressed as a cost). Note that the 'cost' might be £s but could just as easily be time or effort expended - its the legal usage of 'cost'.

As you might imagine this use of 'cost' complicates matters for the engineer and the use of £s for fatality is controversial for some people and the Press. A few companies therefore use some form of formal review in the presence of senior engineering staff to explore the whether ALARP can be judged to have been achieved for the hazards with the worst hazard/risk category.

Tuc, its worth saying that while cost is a legitimate consideration for ALARP assessments, affordability is not. The subtlety is sometimes missed.

EAP

Ogre

10th Oct 2016, 21:13

EAP86

Perhaps SFARP has not replaced ALARP in the UK, but it has elsewhere. In Australia the new WHS legislation makes a big thing over SFARP, and is leading to a lot of time and effort to prove we have done everything reasonably practicable, with requests for details of what mitigations we didn't implement and why not. There may be an engineering interpretation of the term , but there is also a legal interpretation which concerns me.

I'm glad you brought up grossly disproportionate, I didn't want to mention it originally as it would muddy the waters in terms of how you decide you have reached the ALARP/SFARP point.

There is at least one health and safety legislative act currently in use in the world that defines what "reasonably preacticable" is, and grossly disproportionate is only one of the factors to consider. As for the cost of implementing a mitigation, the insurance industry uses the term "cost of preventing a fatality" which in effect puts a monetary value on a human life.

One side effect of this case will be that companies who produce products (and I do mean anything) will need to spend more time and resources providing evidence that they have met SFARP, so that in the event they are taken to court they have a justification for doing what they did. Not much of an issue for your new smart phone, but aircraft, ships, trains, land vehicles all have a greater potential to cause death and injury.

And don't forget driverless cars!

tucumseh

11th Oct 2016, 06:38

EAP86

Good answer. Some years ago, during the Nimrod XV230 debates, it was asked what price MoD places on a life. I recall the formal answer was around £4M, which hadn't been adjusted for inflation in about 15 years. This was later reduced to just over £1M, which meant some proposed mitigations were not longer justifiable, in a financial sense. As you say, they were affordable, but didn't pass scrutiny. The problem, of course, is how to prove how many deaths this will prevent. (The Army got sucked down this path in the 90s and 00s, wasting years on studies and trials, while the solution was obvious and soldiers were dying. Government's facile response is "We're aware, we're doing something, these things take time"). It tends to lead to a reactive, not proactive, system; which is more to the liking of MoD and Government. For as long as I can remember, MoD's risk management strategy was "wait to see if it happens, then think about doing something". When something happens, people die.

This case is actually a very good example. How much would it have taken to avoid it? The regs existed which, if followed, would have avoided it. It cost more to not implement them. You can say the same for most accidents discussed here.

Chugalug2

11th Oct 2016, 07:18

tuc:-
This case is actually a very good example.

Indeed it is, not only in the arcane sense of those technically informed, such as yourself, EAP, Ogre, and others posting here, but also of those with power that is unconstrained by such technical expertise or even the basic awareness of the difference between right and wrong. The dismissal of those dedicated engineers who would not bend to illegal orders to suborn the airworthiness regulations and their replacement with those who were ignorant of the regulations and who did as they were told effectively compromised the system to the extent that it became utterly dysfunctional. Thus it has remained, despite the constant reinventing of titles that merely keep the sign-writers busy.

There will be more tragedies, more avoidable deaths, more waste, until the very deliberate damage to the system is repaired. That can only happen after the Military Regulators and Investigators are independent of the MOD and of each other. That can only happen after the RAF 'fesses up to the actions of some of its Air Marshals, and the cover up since by other Air Marshals.

Fortissimo

11th Oct 2016, 12:09

That can only happen after the Military Regulators and Investigators are independent of the MOD and of each other.

Chug, you mention this view frequently. I don't agree with you. I think there is now sufficient independence because DG DSA answers directly to the Secretary of State for Defence and not to any military person or authority. The Mil AAIB is now within the Defence AIB and entirely separate from the MAA, albeit both are part of the DSA. And on the certification side, military certification standards must also include consideration of any changes to EASA CS25 standards.

If you compare MAA/DAIB with what happens in UK civil aviation, both the CAA and the AAIB are directed in the same way from DfT. The Chief Inspector of Air Accidents answers directly to SofS for Transport, as does Chief Exec CAA. Why should military air safety be handled differently? Do you think the DfT should change its arrangements as well and, if so, how would you separate the responsibilities? Who should CAA and AAIB answer to if SofS DfT is not sufficiently independent? And at what level is it appropriate for these functions and responsibilities to come together?

Brian W May

11th Oct 2016, 13:26

Regarding the shackle, wouldn't you think they'd have fitted a spacer or a sleeve to prevent overtightening.

As in so many things, there has to be a body count. So sad and all to save a groat which has long gone . . .

tucumseh

12th Oct 2016, 05:36

Fortissimo

I think what Chug is getting at is that the MoD is both operator and judge/jury in its own case. The CAA and AAIB are not. The MAA's "Independence" is moot. MoD variously defines independence as "from line management chain" and "commercially". The MAA has, for example, a raft of RAF officers. Do they now have a different line management chain that does not end with CAS? And are the civilians no longer subject to the Ministerial/Cabinet Office rulings that they can be disciplined for refusing to make a false declaration? (Thus risking up to 2 years imprisonment under the Air Force Act, but 5 years for civilians).

The MAA has yet to acknowledge why it exists. If it did, one might be more relaxed about its status. In 2014, its Technical Director claimed to the press "We've asked some difficult questions. That's why we were created". He couldn't have been more wrong. In fact, unless he's been on another planet for 10 years, he's consciously lying. The MAA was created as a result of (mainly) civilian campaigners asking difficult questions about systemic airworthiness failings and fraud by misrepresentation. The MAA continues to deny this, and its MoD colleagues continue to repeat this mantra.

Red Line Entry

12th Oct 2016, 08:38

So what are you after tuc? An MAA without serving military personnel? How will that provide informed, current, knowledge of the Military Air Environment? To answer your question, CAS is not in the management chain for those in the MAA (it goes D MAA to DG DSA to SofS). Yes, of course, people serving in the MAA will return to the mainstream RAF and no doubt you will see this as vulnerability to pressure; but how is that different from those operators working in the CAA returning to the wider commercial aviation world?

And while I do not condone the pressure that you were once subjected to, can you provide current evidence (anytime this century will do) of ANY government individual being disciplined for 'refusing to make a false declaration'? I've never witnessed such an event, nor have I ever heard a colleague express any worry regarding such pressure. I'm not denying your claim that it happended in the past, I'm querying its relevance to the current environment.

Chugalug2

12th Oct 2016, 08:58

Thank you tuc, you put it far better than I, as ever. As you say, both military and civilian personnel within DSA (including the DG) are subject to the MOD CoC, just as they were previously when that CoC subverted Air Safety some three decades ago to leave it in the parlous state it is now. The signs on the door may change, the reality does not.

Fortissimo, the analogy you make with civilian aviation does not bear scrutiny. Yes, both systems come under one SoS (Defence and Transport), but the civilian Regulator and Investigator are separate and independent of each other, whereas in military aviation they come under one DG. If his investigator finds (as it should) the regulator to have failed utterly in ensuring airworthiness in investigating accident after accident is he going to severely censure himself? The throttling of UK Military Air Accident Investigation continues unhindered whereas the AAIB can find Regulator or Operator equally to have failed.

The military operator is of course the elephant in the room, and its principal guise is that of the RAF. It is that Service's Very Senior Officers that first caused the subversion by issuing illegal orders and by illegally granting RTS's to knowingly unairworthy aircraft. It is that Service's Very Senior Officers that have ensured the cover up of that subversion ever since. Thus was the Nimrod Report subverted, thus was the MAA founded on a lie.

It is being freed of such baleful influence that is the essential pre-requisite of UK Military Air Safety reform. That can only happen when the MAA and MilAAIB are outside the MOD, and thus independent of it and of each other.

Lordflasheart

12th Oct 2016, 09:38

.... can you provide current evidence (anytime this century will do) of ANY government individual being disciplined for 'refusing to make a false declaration'?

Unless I've greatly misunderstood, isn't the problem with all this that no-one has actually refused to make a false declaration, knowing that the order to make a false declaration is not treated as an offence, whereas refusing an order to lie is treated as an offence. I am given to understand that this extraordinary policy has been formally confirmed by several successive governments and is still in force.

I suspect that currently (and probably wisely) no-one is actually issuing such orders, therefore there is nothing to refuse, and anything to do with airworthiness is being quietly fudged.

...............

EAP86

12th Oct 2016, 10:39

Ogre,
You are correct, I only had the UK in mind (although I once had cause to read DEF(AUST) 5679!). You say "...to prove we have done everything reasonably practicable, with requests for details of what mitigations we didn't implement and why not." Who is asking this? The legal authorities or the procuring agencies? There was/is a similar issue in the UK. The legal authorities only come into play when, as in this sad case, something goes wrong. The procuring agencies seemed to be the ones asking such questions despite the legal duties only applying to the manufacturer. It can be argued that accepting the Def Stan (00-56) in the contract allows this investigation but it doesn't alter the law of the land nor those charged with responsibility for its observation.

While the UK Health And Safety At Work Act uses "reasonably practicable" it doesn't attempt to define it as it represents a relatively well understood UK legal concept. When the Act was published in 1974, it's contents weren't new, the Act just codified what the Common Law already said about health and safety. I still believe that the translation of SFAIRP into something meaningful for engineers isn't very straightforward. The HSE is quite good at this - their web pages are quite informative - but the guidance has limited utility for manufacturing complex products like military aircraft.

I agree that there can be hard side effects on manufacturing companies, but mostly those whose products have the highest severity hazards in use. I believe such companies need to recognise this and use a safety engineering process from product concept to delivery and in-service. Companies need to recognise that safety engineering is a fundamental part of the Systems Engineer's toolbox. For me Def Stan 00-56 (in any of its early versions) hasn't really been very good at making this clear and in my experience this helps lead PTs to address safety just before entry into service. This approach puts the emphasis on process outputs rather than continuous monitoring and involvement which is the way if they're truly interested in "details of mitigations". I often thought that the requirements of earlier versions of Mil Std 882 tended to be better about the use of safety through product life. Funnily enough, the Eurofighter contractual process is based on the Mil Std as the Def Stan hadn't been published when the contract was signed.

EAP

Red Line Entry

12th Oct 2016, 13:53

...refusing an order to lie is treated as an offence. I am given to understand that this extraordinary policy has been formally confirmed by several successive governments and is still in force. OK, I work for the government, so this is stuff that I should be aware of. Please give me ANY reference document, policy letter, speech or formal source that confirms your belief.

I am not disputing what someone may or may not have said to a fellow PPruner over 2 decades ago, I am simply saying that I do not believe that anyone working in govt today believes, for a second, that refusing an order to lie would lead to disciplinary action.

SpazSinbad

12th Oct 2016, 13:53

Martin-Baker - Ejection History 12mins & ONLY 1946-47
Published on Oct 12, 2016 Martin-Baker (https://www.youtube.com/channel/UCY-J9zTSIV3dg8Z30f-kmlA)
"A brief video showing some of the history behind Martin-Baker and the Ejection Seat." http://www.youtube.com/watch?v=FFAw76CIcq8

Wander00

12th Oct 2016, 17:09

Has this convoluted "orders to lie" stuff been tested in court?

Chugalug2

12th Oct 2016, 22:47

Personal testimony of being ordered to suborn the regulations and being disciplined for not doing so has been posted on this forum on a number of occasions. No doubt it will be so again, but in the meantime I commend the site "Military Airworthiness - A Tale of Mendacity" in which the subject of this thread is covered, together with other military airworthiness related fatal air accidents. The part that covers the issues raised by Red Line Entry is in Part 8.1 "The Elephant in the Room and the Case for Independence" :-

https://sites.google.com/site/militaryairworthiness/MAA/independence

To answer your question Wander00, nothing has been tested in court. Neither the Thames Valley Police nor the RAF Provost Marshal have shown any interest in investigating, let alone laying charges against anyone. I wonder why?

tucumseh

13th Oct 2016, 11:36

Red Line Entry

I've been prepared to publish, twice, what you ask about, under my own name. Cited therein is correspondence from MoD following submission of proofs, when I offered to change anything that was inaccurate. In one reply (28.10.14), the Cabinet Secretary (Sir Jeremy Heywood) referred directly to such disciplinary action and stated it would be "inappropriate" to make any changes to the rulings.

I do not speak of a single event "over two decades ago". I speak of consistent rulings and action since I first experienced this in December 1992. I cannot say if it happened before that, but have opined that it began as a reaction to the Director of Flight Safety notifying the Chief Engineer and ACAS in August 1992 of systemic failings. Until then, relatively infrequent notifications of the same (from January 1988), by MoD auditors, were simply ignored. As a direct result of this 1992 action, the Director Of Internal Audit undertook a 3 year audit and confirmed the failings to PUS in June 1996. The primary aim of that audit was to provide top cover for those who had been threatened with dismissal. Thereafter (to my knowledge) the action taken was "only" formal warnings, which of course have long term effects as they are always brought up at subsequent interviews.

Forgive me if I skip forward into this century, but in April 2003 PUS was advised by MoD's Director of Personnel, Resources and Development that MoD did not regard issuing an order to commit fraud by misrepresentation (making a false declaration) as "wrongdoing" and that adverse staff reports would not be amended to remove references to the offence (the refusal to commit fraud). At 2 Star level, a direct question was asked, in writing - which is the greater offence, the refusal or the order? His written ruling was that only one offence was committed - the refusal. This was subsequently upheld by the Chief of Defence Procurement and (from memory) five Ministers for the Armed Forces. In the same letter (April 2003), PUS was advised that there was only one person in MoD who had voiced concern at systemic airworthiness failings and waste; and that this person was wrong. This claim ignored the raft of internal audits reporting the same. This correspondence followed a formal hearing on the subject in September 2002, which led to CDP issuing his rulings, twice. Civilian staff were advised in writing by their Trades Union (prospect) who, after investigating, decided it could not make a formal complaint about the policy. MoD now claims this formal hearing did not take place, but the transcript of the recording is very clear (as is the recording). My opinion is that, again, this 2003 ruling was (in part) designed to divert attention from a significant event - the loss of Tornado ZG710 the previous month. Part of the original complaint had been that aircraft were being delivered functionally unsafe, but false declarations made that they were safe. It was well known that an inspection of Tornado IFF system integration, specifically failure warnings, had been rejected at 2 Star level in 1999 and 2002, and ACM Burridge in his remarks confirmed the accident would probably have been avoided had such integration been effected properly.

You could write a book.......

NutLoose

13th Oct 2016, 12:14

Regarding the shackle, wouldn't you think they'd have fitted a spacer or a sleeve to prevent overtightening.That assumes you have sufficient clearance and if you do not, reducing the bolt diameter does not detract from the required design strength.
A longer bolt shank so it does not pinch when torqued down due to becoming thread bound may have been the answer, however the length may also be an issue.

tucumseh

13th Oct 2016, 13:10

It has always struck me that the MAA's position, outlined by Red Line Entry, is not dissimilar to anyone with financial and technical delegation. When conducting scrutiny, technical (and it must be technical) staff are seen to be working direct to PUS, as the Chief Accounting Officer. When making their written declaration and signing, they act separately of their line management chain. In the same way the MAA have a more direct link to SofS. But that does not make them "independent", as they have another line management chain which determines their career path far more directly than PUS/SofS ever does. In both cases, the system falls apart because the systemic failures have taken place in that second, more traditional, chain. And, notably, in both cases the PUS/SofS chain has shown no inclination to act upon notification of total breakdown. Set aside, if you like, my evidence, and just ask this. When were systemic failings formally notified by auditors? (13.1.88-on). Who caused them and who judged the complaint? (Same people). Were the notifications repeated regularly? (Yes, every year since). Who rejected them? (Same people). What event brought matters to a head? (Nimrod XV230, and notification of previous reports to the Coroner). Did MoD continue to deny this thereafter? (Yes). Did similar failings continue to occur? (Yes). What's gone wrong? MoD is judge and jury.

So what are you after tuc? An MAA without serving military personnel? I've answered that before. But I offer this, again. MoD has stated, in writing, that only one person believes there were systemic failings. Written in 2003, this claim has been cited repeatedly by Ministers, in correspondence with other Ministers. I'd like to know what MAA staff think of this claim, given the obligation, set out in every letter of delegation, to report such failings and ensure they are escalated. Of course, the claim is nonsense, so one must ask who is writing these Ministerial briefings? And why the MAA senior management is content with them (because they have been notified of them, and in one particular case wrote the briefing). That doesn't sound like an independent organisation. It sounds like one that is scared to stick its head above the parapet. Content to wait for an accident and react, rather than be proactive.

Slow Biker

13th Oct 2016, 13:40

If I could just row back to the safety case issue, in particular #68 and the comment by EAP86. My memory of detail from 15 years ago is a bit sketchy, but I am sure the Mk 10 seat and the Mk9 in Jaguar were considered legacy systems. Now, notwithstanding all the valid comment, regulations and rights and wrongs I think that was how it was.

I expect many have read David Hill's paper on the accident which I admire for the research; however, I find a couple of the arguments a bit weak to present to such a high powered distribution.

Chugalug2

13th Oct 2016, 14:14

SB:-
I find a couple of the arguments a bit weak to present to such a high powered distribution.
Fair enough. Would you please explain? Also I find your comment "a bit weak":-

I am sure the Mk 10 seat and the Mk9 in Jaguar were considered legacy systems
The Hawk Mk 10 seat had no safety case, rendering it unairworthy. No "legacy" consideration can accomodate that!

tucumseh

13th Oct 2016, 16:23

I'm sure any weakness could be corrected, or better explained. But few readers will miss the central point, that it does not contain allegations or supposition, being based on MoD's own statements, and practices Vs policies. Not least, as Chug points out, the Service Inquiry's statement that there was no safety case report. This in itself is a bit of a weak statement, because it doesn't actually say Martin Baker had not compiled a safety case. My guess is they did, but just weren't under contract to maintain it, or under directed sub-contract to BAeS to contribute to the whole aircraft safety cases for all Mk10 users. In other words, exactly the same situation faced by the Nimrod IPT Leader in 1999. But in this case, the IPTs (S&AD and Hawk) had, apparently, passed rigourous MAA audit in the past year; whereas in 1999 it was known and accepted by senior staff that safety cases were not funded properly, the entire process being a bit hit and miss. The SI report does comment on this, but stops short of open criticism. As ever with SI reports, it is very light on events that led to factors and cause.

Slow Biker

13th Oct 2016, 18:18

There was no safety case, but, as I said, notwithstanding all the valid comment, regulations and rights and wrongs, that was how it was. Sadly, the person who could shed a lot of light onto events of those days is no longer with us.
As for 'The Paper', I think very subjective comment, such as MBA saying 'still use this seat' to suggest it should have been upgraded detracts from the more serious issues discussed.
Anyway, said my bit so that's me done.

Chugalug2

13th Oct 2016, 19:16

SB:-
that was how it was

Not only was but is in my view. The point that tuc and I are making is that how it was has led to 63 deaths in airworthiness related accidents and how it is will go on doing so unless some really radical steps are taken PDQ. The RAF has to confront the elephant in its own room, which is the continuing cover up of illegal orders and illegal actions made by its own Very Senior Officers. Only then can the Nimrod Report be seen as part of that cover up. There was no "Golden Period", quite the contrary there was deliberate sabotage of the UK Military Air Safety system. Once the Nimrod Report is seen as the sham that it is then the MAA, which proclaims Haddon-Cave as its corner stone, can likewise be seen in its true light. Regulation and Investigation is not safe in the MOD's hands and must be wrested free of them and of each other. Then and only then can the long and difficult road to regaining UK Military Airworthiness be started out on.
Anyway, said my bit so that's me done

There was an MOD apologist that was forever saying much the same on the Mull thread, yet he returned time and time again. So stay with the conversation SB. Jaw jaw, and all that...

Slow Biker

13th Oct 2016, 21:33

Okay, okay, I'll stay with it, but really, I don't think I can add much to the conversation. I'm on the same side as you and tuc and I understand how safety has been eroded by VSOs and their drive for budget cuts and then turning a blind eye to the inevitable results. Reading some of the learned posts on this site has made me think how poorly I was trained (!) and prepared for the role I undertook; I had to work it out as I went along, just making sure I didn't do anything stupid. I suppose that fits in with many of the arguments you both make.
Gotta go now for the unbiased Brexit argument on Question Time!

tucumseh

14th Oct 2016, 00:12

Slow Biker, with the greatest respect you have already added much value, simply by accepting the truth of what is being said. A few here endured much criticism when these failures were first raised, many repeating the MoD line that such things could never happen. Now, dare I say it, it is only a few hard liners who refuse to accept the facts laid bare before Haddon-Cave and Lord Philip. It is often better to read the evidence before trying to refute it. Especially when it is in MoD's own hand! I don't make accusations here, simply note MoD's own statements in an attempt to explain accidents like this. Very unoriginal I'm afraid.

Chugalug2

14th Oct 2016, 06:41

Slow Biker:-
Okay, okay, I'll stay with it, but really, I don't think I can add much to the conversation

On the contrary you have already added much. Your own experience emphasises the dysfunctional system that meant that you were left simply hoping not to be the one that acted wrongly out of ignorance. It was not your fault not being fully informed but of those that rendered the system dysfunctional to such a gross extent. As you say we are all on the same side. We all want UK military aircraft to be airworthy. It will take all of us to demand that real reforms rather than pretend ones make that happen. As to learned posts, they certainly don't come from me! I was a lowly GD/P. They don't come more unlearned than that!

Come on in and join the fray! I must though regrettably end on a note of mild censure. Question Time biased? Really Sir, how can you suggest such a thing? :E

hoss183

16th Jan 2017, 15:41

Its in the news again today.. Ejection seat firm in court over Red Arrows pilot death - BBC News (http://www.bbc.com/news/uk-england-lincolnshire-38637154)

MB make something that has saved many lives, but which does that by employing some dangerous and violent methods in a last resort solution. And all that with an excellent record.
I really don't see how this is justified in general with the above said, and specifically when having read the report which doesnt seem to point much to MB being at fault compared to other factors.

tucumseh

16th Jan 2017, 16:42

050

Agreed, and well said. There is so much evidence to counter MoD's main claim. It may be that other evidence has yet to be revealed. But for MoD to escape prosecution, it will have to be much worse than ACAS falsely declaring in the RTS that there was a valid safety case. Of course, MoD has form here, and has escaped prosecution before. I really do wonder why MB haven't played this, and other cards.

hoss183

16th Jan 2017, 17:02

thank you tuc
I guess its a case of 'how much do you want to drop one of your primary customers in the poop?' I hope this sorts itself out in the wash, perhaps the deal has already been reached behind the scenes... a court case for appearances and then business as usual.

Chugalug2

16th Jan 2017, 20:07

hoss183:-
perhaps the deal has already been reached behind the scenes... a court case for appearances and then business as usual.

If that is the case then MB and the MOD would jointly be guilty of conspiring to pervert the course of justice. The MOD of course wouldn't bat an eyelid, but MB needs to consider its actions carefully. Nowhere is "behind the scenes" these days. MOD's attempts to pin a manslaughter rap on two deceased JOs is already a matter of record. In short it has form.

Now another man has died, let right be done, and the real culprit be put up for trial.

oldmansquipper

17th Jan 2017, 12:53

An observation, if I may?

Re: 'how much do you want to drop one of your primary customers in the poop?'

For several years, the UK MoD has been at best, a `secondary` customer for MBA. However, I believe the perception that "if its good for the RAF, its good enough for us" still (up to ~5 years ago, anyway) held sway with many of the company's other customers.

...but I get the points Hoss and Chug.

Fonsini

17th Jan 2017, 14:28

All the legalities aside, the accident report was chilling and informative at the same time, and an excellent piece of work in my opinion (I write reports for a living).

It makes me wonder how many flight crew have accidentally passed a crotch strap through the ejection seat D ring when strapping in and not noticed it. I have seen flexible "crotch shields" on some aircraft that would have prevented this from happening, I believe the early JAS39 seat required some work in this area. It certainly made me think.

A tragedy all round.

RetiredBA/BY

18th Jan 2017, 08:48

I find it extremely difficult to understand why ANY pilot could not be utterly meticulous about checking and strapping into his seat, to have any strap out of place , let alone one through the firing handle and no notice the fact is absurdly bad airmanship.

And I still can't imagine why the pin was being replaced on the roll out with other aircraft in the vicinity, why on earth does, or perhaps did, the RAF allow such sloppy procedures?

Pins should only be installed when , ideally stopped, but only when circumstances allow visual confirmation of correct insertion. Period

When I first started on a JP 1962 my QFI hammered into me that the seat could save my life, but if mishandled could just as easily kill me.

Six months later we both ejected and he is coming to lunch today !

All my RAF life, particularly as a QFI myself, I practiced my QFIs teaching
, what changed ?

Chugalug2

18th Jan 2017, 10:17

RBA/BY, your point is well made and I too remember both the sense of security and the respect that was drummed into me when under instruction on the JP at the same time as you were. As a trainee trucker first the seat went, leaving only a parachute for the Varsity AFTS, and then even that went at the Hastings OCU (bad for passenger morale apparently).

The change in culture that you instance is what happens when an Air Safety system is deliberately and malevolently attacked. It is wrong to suppose that airworthiness alone was a victim of that attack in the late 80s/early 90s, every aspect of Flight Safety was hit; reporting, collating, rectifying, disseminating. Add to that the truculent view that "Safety is for Wimps" and you arrive at the cavalier practices found in this report.

It took mere months to destroy a system that had taken decades to build. It will take more decades to rebuild, and that has to start with an independent Regulator and Investigator, both of the MOD and of each other, in order to avoid a repeat attack. That is the point of an Investigation after all, to avoid a recurrence!

For too long BoIs/MIs have satisfied themselves with counting the trees when it is the woods that need investigating, and that can only be done by investigators independent of those with something to hide.

Stuff

18th Jan 2017, 11:45

And I still can't imagine why the pin was being replaced on the roll out with other aircraft in the vicinity, why on earth does, or perhaps did, the RAF allow such sloppy procedures?

Pins should only be installed when , ideally stopped, but only when circumstances allow visual confirmation of correct insertion. Period

I'll go fetch a ladder so you can get off your high horse safely.

The existence of position 2 and 3 for the SFH were not known about and neither was the possibility of initiating an ejection with anything other than a vertical pull.

The best knowledge at the time was that if you had inserted the pin then the SFH must have been safe. No visual inspection was required, why would it be? The pin wasn't believed to be capable of going anywhere else. In any event, a visual inspection of the pin when the SFH was in position 2 or 3 from the normal seated position would simply show the pin to be "correct" as looking at it from above wouldn't show the problem.

Bob Viking

18th Jan 2017, 12:29

Retired BA/BY

It's easy to criticise but unless you were in Sean's shoes then it is very hard to say you wouldn't have done the same thing.

We are all taught (and for us QFIs we all teach) to be very careful with pins and respectful of EJ seats. Nothing has changed in that regard.

All I can say is that Sean learned a very hard lesson for the eternal benefit of the rest of us. I check my seat pin far closer now than I did before his accident. As Stuff says, we just weren't fully aware of the problem beforehand.

I'm not overly chuffed when people come on here and say things like "I would never have done that" and "what the hell was he thinking?!".

The quote 'Don't judge a man until you have walked a mile in his shoes' springs to my mind. You may well have been a previous FJ pilot and you may have achieved thousands of hours in them but you weren't a Red Arrows pilot in 2011. If the criticism had come from one of the team then I would listen. To the best of my knowledge, this has never happened.

You may disagree with me and I'm not trying to start a fight but those are my thoughts. As a counter argument how would you feel if I were to come onto a similar forum and bad mouth the actions of a BA pilot after a fatal accident? Sure I'm a pilot but I've never flown a heavy transport aircraft.

BV

falcon900

18th Jan 2017, 13:25

Bob Viking,
Surely the fact that the pilot was a member of the Red Arrows in 2011 raises the bar in terms of standard of care?
We surely don't need to await a pronouncement from someone else in the Red Arrows (as if there is likely to be one) to be able to conclude that the crotch strap through the handle was bad form, and was down to the pilot? I am not trying to deflect the general flow of the debate,or alter where the fingers are pointing, but lets call a spade a spade.

Bob Viking

18th Jan 2017, 13:40

Falcon900

The question of why an experienced operator incorrectly routed his crotch strap may never be answered, although the SI goes to great lengths to attempt to explain. Sean wasn't the first to do it and I'm sure he won't be the last.

I'm not saying it was correct to do so. Sean knew that as well. I just find it a little specious to state that 'it could never happen to me'. You could say that for every accident that ever occurred. The victim of the accident would probably have said the same. But they'd be wrong.

I think I've made my point but I'm sure there is more to discuss.

BV

RetiredBA/BY

18th Jan 2017, 19:50

Stuff: No need for a ladder, checking visually that the pin was correctly installed is too utterly basic to ignore. Never heard of double checking a critical item, in this case feel and visual observations ?

And as far as Mr Viking is concerned I HAVE walked in very similar shoes to Sean's. So I am VERY critical of the idea of inserting a seat pan firing handle on the rollout and NEVER saw it done because it was certainly not SOP. I question just why it was necessary to insert the pin before safely stopped and parked on the pan. Perhaps there was/is a reason I just don't get it based on the experience of 12 years of flying ejection seat equipped aircraft. After this accident and the associated publicity its a pretty poor state of affairs if Sean is NOT the last to do this. I am not bad mouthing anyone, just critical of the culture based on real life experience and if you wish to be crtitical of any other incident feel free to do so, BUT make it factual and preferrably based on real knowledge or experience.

Never a Red but there have been times when I was rushed but seat checks were NEVER compromised. Perhaps an ejection very early in my career rammed that home and I hammered that home to all my crew and students ( which included commandants designate of CFS and RAFC when I was a standards QFI) for which I make no apology. It served me well.

I could never, ever, say it could NOT have happened to me but I did my damndest to make sure it did not and that includes the double check I mentioned.

Fonsini

19th Jan 2017, 00:12

Actually Bob the accident report did address that question. They believed the previous pilot flew the aircraft in the exact same condition, and that he exited the cockpit with the now undone crotch strap lying loose but still routed through the seat handle, Sean didn't pass the strap through the handle, it was already there. On recreating the scenario the examiners noted how easy it was to reach down and grab the strap without being able to see the mis-routing.

No need for ill-feeling over this, it was a tragedy and lessons will be learned. RIP Sean.

Chugalug2

19th Jan 2017, 11:18

This needless and avoidable accident should send out a clarion call to the military aviation community of the importance of a fully functioning Air Safety System and what can happen when there isn't one, as then, and as now.

This seat did not have a Safety Case. If it had then a continuous auditing process would have highlighted the possibility of the drogue shackle nut being overtightened as a result of the improper use of an RTI requiring the nut to be unfastened and refastened on the line every 50 hours. It would also have highlighted reports of the SPH pin being inserted leaving the seat live, and for that matter the ease of misrouting the crotch strap through the SPH, and measures would have been taken to alleviate all of these issues.

There was no Safety Case though, and the aircraft RTS was therefore illegal. There was no overview of this vital safety component by the Regulator, rather all was left to the airmanship of the pilots and the professionalism of the ground engineers. The Regulator should be in the dock in my view, attempting to defend the indefensible. Unless and until it is, then needless and avoidable accidents will simply carry on happening...

MACH2NUMBER

19th Jan 2017, 13:26

I am obviously a bit old fashioned. Safety Cases came in, possibly in the late 90s, not sure, but I sat on ejection seats for 40 years, not just MB, but also Folland and ACES 2. I recall safety being absolutely drummed in to us in initial training and beyond. Particularly partial pin insertion and crotch strap positioning. I don't recall many or any such cases like this one.
This was an absolute tragedy and I do not blame Sean in any way. Despite all the training, I managed to get airborne on a live Q scramble with the straps completely wrong and the seat live. With some trepidation on the climb out, I made the seat safe, unstrapped and did it properly. Things can screw you up and I was lucky nothing else happened. Will a safety case make you absolutely safe or is it just a legal requirement? I don't know.
What I do know is I am grateful for the security that an ejection seat gave me and was happy to sit on one despite its own inherent dangers.

tucumseh

19th Jan 2017, 14:17

Safety Cases came in, possibly in the late 90s

This touches on a much misunderstood aspect. While Safety Cases were mandated in the early 1990s, that is not to say safety was ignored before that. It was just called something different - the Safety Argument for example. I still have my copy of the mandated regulations procurers were under, dated 1977. They underwent a major update in 1985, which added chapters; but the original 10 remained extant and mandated. (For example, managing software projects became a bigger aspect of our work and specific regs were added). In the section covering contract acceptance, safety features heavily. In other words, and regardless of what the bit of paper was called, if the contractor couldn't prove the product met its safety criteria (set out in the project plan from day 1) then it was not accepted off contract by procurers, and (obviously) could not be offered to the Service and accepted into Service. Nor, obviously, could a Release to Service be issued (legally).

All contractors understand this, and very few in my experience would remotely consider defrauding MoD by falsifying safety reports. (I'd like to say "none", but unfortunately I know of two - both led to multiple deaths and injuries, but no action was taken). The problem, admitted by MoD in the Service Inquiry report, is that this process broke down catastrophically in the case of the Mk10 ejection seat. I'd bet my house Martin Baker has a valid Safety Case. As I'd still have the house, I'd bet it again that MoD has not had Martin Baker under appropriate contract, so the MoD Safety Cases have lapsed or just been ignored - and this is what the SI refers to when it admits there is no Safety Case.

In other words, precisely the same as happened on Nimrod MR2, when MoD didn't bother contracting its upkeep for many years, and when an attempt was eventually made to resurrect it, it employed a safety manager who hadn't a clue, as it had been so long since MoD trained anyone. (And therein lies the reason he, and his RAF officer colleagues, were not prosecuted). Which gets us back to XX177 and why (a) the Crown prosecution Service determined that no case could be brought, and (b) the Health and Safety Executive have decided to pursue Martin Baker but not MoD, despite the latter openly admitting serious offences. Something's going on.

MACH2NUMBER

19th Jan 2017, 15:04

Tuc, many thanks for your comeback, your further explanation and correct dating. However, I am still unsure as to whether a Safety Case really makes things completely safe or is just a legal requirement, giving the opportunity for litigation when it goes wrong. Military aviation is inherently dangerous, thats why I am going grey! I prefer to talk in terms of airworthiness, where I have had some experience, not all good I might add.

tucumseh

19th Jan 2017, 15:28

Mach2number

I agree. It adds a degree of confidence - a high degree if done properly. The real issue is, as you say, practical implementation. The Safety Case for the seat (in this case) must then be subsumed into the whole aircraft Safety Case for the platform, and what is safe in one application may not be in another. That is why the SI report is so alarming - that the MoD system, post-MAA and Haddon-Cave, permitted the basic Safety Case to be ignored. Put another way, what MoD tends to ignore is the difference between physical and functional safety. It (or rather the manufacturer) will usually check the first, but MoD uses that evidence to sign off both. Martin Baker can say the seat is physically safe, but it cannot say it is functionally safe as it has no control over how it is fitted, maintained or used.

Haraka

19th Jan 2017, 15:51

I know that I have asked this (professionally unqualified) question before.
Is there any possible circumstantial link between the events surrounding the death of Sean Cunningham and that of Steve Beckley, who apparently stepped on the bottom handle of his seat ( pins in )and was ejected to his death on ground impact whilst climbing out of a Harrier at Yeovilton c.1974.?

superplum

20th Jan 2017, 07:56

Yes, the SPH issue is not new. It did occur on a Harrier years ago but I don't recall a fatality linked to it. I do remember that the SPH issue was then highlighted in Air Clues or on a poster.

Timelord

20th Jan 2017, 08:04

Haraka,
This is only my recollection but I believe that in the Yeovilton case the SPH had not been inserted at all. When the pilot stood up on the seat he stood on the handle which pivoted around the QRB and fired the seat. In the train of events leading to Sean's accident of course the SPH had seemed to be inserted but wasn't in the right place.

RetiredBA/BY

20th Jan 2017, 09:50

Question for Viking, whom I assume is a Hawk QFI:

In my time in the RAF as a QFI, albeit 40 years ago, before we entered the jet the first thing we did was check all seat and canopy pins in place.
Then we kneeled on the seat facing aft and did a thorough seat check, including such vitals as the top latch alignment, attachments of sear pins etc. and correct harness alignment.

It was done on each and every flight, just as we did an external check of the airframe.

Have things changed ?

Bob Viking

20th Jan 2017, 14:36

You assume correctly regarding my profession.

Aside from the fact we no longer kneel on the seat to conduct our checks nothing has changed.

BV

overstress

21st Jan 2017, 16:43

The existence of position 2 and 3 for the SFH were not known about and neither was the possibility of initiating an ejection with anything other than a vertical pull.

Maybe not known about at the time. As I stated earlier in this thread, this was shown to my course in 1986 by the GS Sergeant instructor, on the seat in the classroom. I clearly remember the demo of the sear pulling out and used to check on every occasion. I subsequently flew Tornado and then Hawk again as an instructor and continued to check. Somewhere along the line the corporate knowledge was lost.

Maybe that ground school lesson wasn't structured and this potential glitch wasn't on a syllabus, maybe it was just that particular tech instructor, and when he moved on his successor didn't know, or failed to teach it. I suppose it's incumbent on those in instructional roles to ensure that lessons are properly structured and that hopefully such potential mistakes are not forgotten, as seems to have been the case here.

Bob Viking: You may well have been a previous FJ pilot and you may have achieved thousands of hours in them but you weren't a Red Arrows pilot in 2011.

I'm not sure what your argument is. It doesn't matter what role you operate an aircraft in, in this case the Hawk, you could be Red 1-10 or a Unit Test Pilot, the equipment is the same. I hope you're not saying that the RAFAT cannot learn from anyone else other than the RAFAT, or that once you hang up your g-suit, your experience no longer counts?

Slow Biker

21st Jan 2017, 21:32

On the units where I served the issue of how the SPH safety pin could be incorrectly fitted was demonstrated in the mandatory six monthly ejection seat lecture for all personnel who entered a cockpit with a seat installed. Of course it is easy to see on the training seat, but a different matter when sitting in the aircraft. There was a campaign to increase the frequency of these lectures; I wouldn't be surprised if today they have ceased altogether.

Bob Viking

21st Jan 2017, 21:44

I'm obviously being far too subtle so I shall spell it out. My beef started with post 186.

Retired experts coming onto a thread such as this and criticising a guy who died in an accident and making out that it would never have happened to them because they're far too clever and were taught much better back in their day.

Someone pretty much makes out that Sean's accident was his own fault and I'm the only one who thinks that's out of order?!

If I am the only one then I apologise profusely but I doubt very much that the RAF of yesteryear was any safer then the RAF of today.

That's about as polite and obvious as I can manage.

BV

overstress

21st Jan 2017, 23:24

it would never have happened to them

BV. The point is, it didn't happen to them, or you, or me. But I'm saddened when I see a life lost in a case such as this where continuity of knowledge just might have prevented it.

Perhaps as you are still in the Hawk role, as I was, it's difficult to accept that the viewpoints of others outside may have relevance. One day you will hang up your g-suit but you may find that you never truly 'leave' the F-J world. Will all your experience suddenly become worthless?

Bob Viking

22nd Jan 2017, 06:40

It's one thing to have an opinion. Quite another to use an anonymous website to air it for all to read.

The SI has clearly brought out all the lessons and everyone is now well aware of them for the future. I get that some of these lessons were already known about. Saying "I told you so" changes nothing.

You, and others, seem to think I have something against retired guys sharing the benefit of their experience. That is not correct. I do have something against retired guys sneering at the RAF of today and pretending everything was better when they were in. If that is not what you are doing then I don't have a beef with you.

Let's look at this from another angle. The longest running thread on this forum (that I am aware of) was the Chinook Mull of Kintyre thread. What if I had posted on there that I thought the pilots were to blame? Would you expect everyone to sit back and say "that's alright, BV, you're entitled to your opinion"?

Anyway, since I appear to be the only one who took issue with RetiredBA/BY's original post I'll give it a rest.

BV

overstress

22nd Jan 2017, 10:19

People use anonymity on here for valid reasons. However I'd be happy to identify myself if you PM me. I'm personally gutted that Sean died in those circumstances. I don't think anyone is saying "I told you so", in my case (especially as an ex Flight Safety Officer) I'm just concerned that such a well-known gotcha (there were posters everywhere, some archived on this site) somehow got forgotten over time. No-one is sneering and I'm sure that BA/BY didn't intend that.

As you know, accidents usually involve a chain of events, holes in the cheeses. The handle was one link in the chain, the bolt torque another.

All the best

Chugalug2

22nd Jan 2017, 12:54

overstress:-
As you know, accidents usually involve a chain of events, holes in the cheeses. The handle was one link in the chain, the bolt torque another.

To which I would add the lack of a Safety Case Report. That alone meant that the Hawk was unairworthy as it lacked a legal RTS. Why didn't the MI pursue that, having creditably unearthed the lack of the Report? "It was outside its remit", do I hear? That in a nutshell is why UK Military Air Regulation and Accident Investigation should be independent of the Operator and of each other.

BV, I'm afraid that I disagree therefore with your claim that

The SI has clearly brought out all the lessons and everyone is now well aware of them for the future.

as for

I do have something against retired guys sneering at the RAF of today and pretending everything was better when they were in

I can only say that I do have something against serving guys who portray those of us who are retired but care deeply for those like you who still serve in such a negative way.

The chain of events that led to Sean Cunningham's avoidable and tragic death started back in the late 80s/early 90s in my view.

Enough has been posted here in the Chinook, Hercules, Nimrod, Sea King, Tornado, and now Hawk airworthiness related fatal accident threads to point up that common root cause. Yet still RAF Investigations, and the MAA (nee MOD) Regulator fail to recognise it. That is unprofessional to say the least, and won't draw the lessons that prevent recurrence. If that is sneering, then I am guilty as charged.

Like overstress, if my PPRuNe ID is anathema to you I am quite prepared to reveal my true one to you via PM.

dervish

22nd Jan 2017, 13:17

Good post Chug. You need to keep making your point. There might have been a problem with the seat or how it was used, but why was the aircraft in use?

MACH2NUMBER

22nd Jan 2017, 14:33

dervish,
Why don't we just ground everything, no problems then. I would bet in hindsight that no military aircraft from day 1 even to the present would pass the current criteria.

Heathrow Harry

22nd Jan 2017, 15:52

That's what happens after a prolonged period of peace

In war time you accept the risks, as peace draws on the risks seem less and less justifiable

drustsonoferp

22nd Jan 2017, 16:09

There seems to be a significant attitude from ex-serving former aircrew that things like this would never have happened in their day, or even more interesting, that they knew about the weaknesses of the seat pan firing handle design years ago and were told to look out for it.

The seat pan firing handle modification is very simple. If the culture of yesteryear was so wonderful, the standards of safety so great, how did no one manage to recommend a modification, report the unsatisfactory nature of the equipment they were given to use, or otherwise put anything in writing so that any apparent knowledge was more than anecdotal?

Reviews after the RAFAT event were extensive, and widely regarded to have revealed new information, not previously understood. If there were any indication that such things were known years ago, it is a failing of the previous generations to document them properly which lead to this.

Rather than smugly state how you would never have done something similar, and that standards must surely have slipped in the intervening years, ask why you never thought to raise a F765X - if you can genuinely say you understood the problem then as it was later revealed.

MACH2NUMBER

22nd Jan 2017, 16:30

Dru.
The problem not so many years ago was that we were taught procedural safety as a foil to absolute physical safety (which is unachievable). I doubt anyone knew what a F765X was and would probably not have been encouraged to submit one.
I for one do not have the attitude to which you refer, and resent that particular line of yours. I believe that by luck of God this didn't happen to me and many others.
However I refer you still to my earlier post.

drustsonoferp

22nd Jan 2017, 16:43

Mach2,
I don't claim this attitude is universal, nor that you exhibit it - clearly many of you do not, but it is notable in this thread.

Chugalug2

22nd Jan 2017, 16:45

M2N, if I might respond while we await dervish. The MAA seems to be doing as you suggest regardless of the reform that I propose, having rid us of our MR force and the ACO's Gliders (Oh sorry that's a "pause" isn't it?). I assume that you don't seriously propose what you have posted. Whatever the state of our operational fleets, they have to remain available for our defence no matter. Any Regulator, whether it be the MAA (nee MOD) or one independent of the MOD simply has to do the best with the hand it is dealt. The problem is that the MAA won't admit what the hand is that it has been dealt.

The MAA proclaims its bedrock to be Haddon-Cave's Nimrod Report. It is not bedrock, it is sand, hence the parable quoted earlier. By claiming the period late 80s/early 90s to be a "Golden Period" of airworthiness it sought to obscure the lasting damage to UK Military Air Safety rendered by RAF VSOs in that very period. Unless and until the RAF and the MAA face up to that fact (which they haven't so far in order to protect those same VSOs) then the extent and effect of their subversion cannot be assessed, and further accidents as covered by this thread can be expected.

HH, wartime risks are one thing, but aircraft that self combust or ejection seats that kill their occupants are unacceptable in peace or war.

drsoe, this isn't about being wise after the event, or worse still before it and saying nothing, this is about aviation. It will try to kill you given half a chance. You point to mods made to the MB seat that would have saved Sean Cunningham's life. Very good, but they didn't did they? Too little and too late! If the seat had a Safety Case Report, and the RAF a Flight Safety System that had fed back those 765's in good time, then such mods would have been incorporated without anyone having to die.

I understand the resentment of those doing the doing while we old farts simply hammer away at keyboards. We all want the same thing, the avoidance of avoidable accidents. That can only happen if we face up to reality. I maintain that the MAA has yet to do that.

MACH2NUMBER

22nd Jan 2017, 16:59

Chug,
You are correct, it was tongue in cheek; however, as an ex Wg Cdr Spry, I always sought for open reporting of FS issues. It was an uphill battle, particularly against many sensitive engineers and VSOs. We nearly got there, but the hierarchy in the 80s brought open reporting down by trying to find out who the 'open' were. Things became even more difficult in the 90s.
I could go on, but..

Chugalug2

22nd Jan 2017, 17:07

Well perhaps you should M2N. Unless those like you, who experienced the pressures to just shut up and go away, testify to it here then we are all tarred with the same brush wielded by dru.

Bob Viking

22nd Jan 2017, 18:27

It looks like I will need to spell it out again.

I find it extremely difficult to understand why ANY pilot could not be utterly meticulous about checking and strapping into his seat, to have any strap out of place , let alone one through the firing handle and no notice the fact is absurdly bad airmanship.

And I still can't imagine why the pin was being replaced on the roll out with other aircraft in the vicinity, why on earth does, or perhaps did, the RAF allow such sloppy procedures?

The above was posted by RetiredBA/BY. You added that his post was well made. I don't really have an issue with you or others that seem to think I'm taking a pop at them. Indeed your posts are usually eloquent and well considered. You do come across as a little precious though by assuming I'm grouping you in with my initial statement.

I don't need to know your identity or that of anyone else. My point about anonymity is this. Would RetiredBA/BY happily walk up to the family of the deceased and state to their face that he believed their son exhibited absurdly bad airmanship? I doubt it very much. If he would then he is not someone I would wish to associate with.

Your points on this thread are about safety cases and the broader picture of RAF flight safety. You will notice I'm not getting involved in that. I could not add to your well made points and my knowledge would pale into insignificance against yours.

It is heartening to know that others agree with me (I have had a few PMs along these lines).

So please take my points as they were intended and don't think that I am in any way ageist or that I don't appreciate your support. The way you jump on drustsonoferp does reinforce my point somewhat though. As knowledgeable and wise as you are no-one is beyond criticism.

I hope I have, finally, made my point clearly enough.

BV:oh:

RetiredBA/BY

22nd Jan 2017, 18:32

As Viking is probably reading thus let me make it absolutely clear that I was certainly not sneering at anyone, thats nonsense. Nor am I saying that things were safer in our day, they certainly were not, that was my point. We lost Lightnings at a dreadful rate, mainly reheat fires, the Canberra, a big Jet Provost on two but was a potential killer on one, killing even the Marham (Wyton ?) station commander near the end of its career in an asymmetric accident, to name just two. It gave me two nasty frights with engine failures at critical times, both outside ejection seat limits.

The number of Meteors lost in the '50s too, was truly dreadful, over 800.

A lot more Gnats were lost at Valley than Hawks, in which I have had a couple of flights, including XX310 now a Reds aircraft, Vampire T11s, on which I trained, too. Modern aircraft, civil and military, are vastly safer and more reliable than we had in the 60s but that is no reason to relax safety standards, and certainly not a reason to ignore the hard earned experience of your predecessors. I can still remember many aspects of my own ejection when not everything went exactly to plan.

I don't sneer at anyone and certainly not in a dreadful accident such as this.

But I will make one thing clear. As a former airline air safety officer and a member of the U.K. Flight safety committee, including two years as its Vice Chair, I Absolutely believe that if you are serious about safety you have to be brutally honest, no sacred cows, no, or as little emotion as possible, you need to get at the truth in order to prevent a recurrence.

I have no idea how the current "safety reporting system" works in the modern RAF, it seems to have some problems, but in civil aviation we created a "just culture" system. Creating it was hard work but it has created an incredibly high standard of safety in civil ops. The RAF may well have something to learn from it.

And just for Vikings point , I well know the personal effect of a fatality on families. My wife's sister was killed in an aircraft accident in which her brother in law, the pilot taking off at their farm strip, and their child survived . I have seen first hand the effects on the family, particularly the parents, it was truly dreadful not least because my father in law pulled. His dead daughter from the wreckage. . We are still unsure of the root cause but there are never any reasons not to try and get at the truth, human factors or technical, in order to prevent a recurrence and I know my parents in law shared that view.

So, of course I would hate to be in the situation you suggest, but is my absolutely sincerest wish that Sean' s loss will not be totally in vain if it prevents a recurrence.

dervish

22nd Jan 2017, 18:49

Mach2number

dervish,
Why don't we just ground everything, no problems then. I would bet in hindsight that no military aircraft from day 1 even to the present would pass the current criteria.

Others more knowledgeable have answered this same question on other threads. The best answer is, and I paraphrase, what regulations do you think should now be waived? You may be correct about other military aircraft, but that just highlights that for seven years the MAA have been rewriting the regulations, when Hadden-Cave confirmed the problem was lack of implementation. If you keep looking at the final act, the seat cock up, you miss the worst failure of all. No safety case is indefensible.

overstress

22nd Jan 2017, 18:59

ask why you never thought to raise a F765X

I'm fairly sure that the F765X is a relatively recent thing, I'd never heard of it, had to google it. Perhaps someone can say when it was introduced.

drustsonoferp

22nd Jan 2017, 19:56

F765X is the current form to request an amendment to Aircrew publications. Presumably there were others before it, or other mechanisms to request an amendment to publications?

Chugalug2

22nd Jan 2017, 20:01

BV, if I came across as precious or jumpy I apologise. As to being knowledgeable and wise, I'm old that's all, but that has some merit for anyone who's been aircrew in itself. Like overstress, I too was an FSO and was lucky enough to be that it seems at the zenith of the RAF Flight Safety System (merely going by what I have since learned on PPRuNe).

I didn't take BA/BY's post as being anything other than one of commenting on the published findings of the SI. You think that posting that is hurtful for his loved ones. I can only say that the greatest support experienced on other Airworthiness Related Fatal Accident threads has been from families of the deceased. More than anything they wanted others to be spared the pain and suffering they had experienced in losing their loved ones. It was they who castigated MOD apologists trying to shut down debate in their name!

Every tragedy is unique I know, but we cannot hope to avoid further ones unless we consider everything involved. The elephant in this room, and in all the other fatal accident threads, is the UK Military Air Regulator, aka the MAA, aka the MOD. It is fatally compromised and reform is urgent. If you are a UK Military Aviator that must concern you, it certainly does me and I'm retired! I have learned more about Military Air Safety on this forum than I ever did while serving. As an ex Flt Lt pilot, if I can do that so can you. Then you can become "knowledgeable and wise" too! :ok:

MACH2NUMBER

22nd Jan 2017, 20:06

Derv, Chug et Al,
I am obviously not knowledgable. I hold no candle for the MAA. Neither would I cite waivers - I have been out of the RAF for 10 years. I merely state my opinions as follows: In the early 1980s, the RAF sought, maybe optimistically, to bring in a system of open reporting, without prejudice. All were encouraged to report incognito, any aviation problems, outside of the 765 system. It started well, but as it happened, some tried to find out who the 'incognito' were. Trust became lost, a period sometimes referred to as 'Flight Safety by Cruxifiction' ensued. Open reports dried up because punishment was possible. So here we are now 30+ years later, the lawyers have taken over the cruxifiction and any quick way of learning aviation lessons, short of accidents, has probably been lost for ever.. Its all very sad. Here endeth my last post on this issue.

overstress

22nd Jan 2017, 20:39

Drustonferp, I (ahem) may have a dusty, mildewed copy of the Hawk aircrew manual somewhere. When I get home from my trip I'll look it up. I do recall some form of wording in the front saying any amendments should be addressed to OC Handling Squadron. It's a good point and I will be interested to see what the chapter on the Mk10 seat had to say in 1997.

Chugalug2

22nd Jan 2017, 22:15

overstress and dru. I might have (ahem) a copy of Hastings C Mk1 Pilots Notes. If I did, then the Notes to Users (AL2 May 61) would say that comments and suggestions should be forwarded to OC Handling Squadron, RAF Boscombe Down. But only if I did, you understand...

BEagle

23rd Jan 2017, 04:39

When I did a refresher course on the Hawk at Valley in 1980, I was briefed very thoroughly about the need to check that the seat firing handle was fully 'down' in its housing when reinserting the pin. Also that this had to be done visually, not by fumble and feel (e.g. the JP guillotine pin).

Same at Chivenor on the first of the new courses; brakes on, engine shut down, then L00K and replace the seat pin, then the canopy pin.

With a zero/zero seat, it would be utter folly to replace the pins with the engine running - should there be a fire, it might be your only way out!

tucumseh

23rd Jan 2017, 06:30

mach2number

The problem not so many years ago was that we were taught procedural safety as a foil to absolute physical safety (which is unachievable). I doubt anyone knew what a F765X was and would probably not have been encouraged to submit one.
The use of MF765 (Unsatisfactory Feature Report) is laid down a number of documents, the primary one being the mandated procedural Defence Standard that controls maintenance of the build standard (now cancelled without replacement) – without which the safety case cannot be validated and no Release to Service can be issued. There, gliders in a nutshell.

In the early 1990s, funding to do this was cut by 28% per year, for over 3 years. Direct orders were issued not to use the MF765 (or MF760 fault reporting) systems – part of the “savings at the expense of safety” confirmed by Mr Haddon-Cave; although he dated them to 1998, not 1987, despite the actual documents and directives being submitted to him. There, systemic airworthiness failings in a nutshell.

While some of this work has been resurrected, by no means all – evidenced by the much abbreviated definition of it in the MAA documentation. Plainly, no-one in the MAA has ever managed such work before. There, current problems in a nutshell.

Sorry, to seem a little pedantic, but you mean functional safety, not physical. But you are right – very few are taught how to achieve either. And anyone who doesn’t know what a MF765 is, shouldn’t really be allowed near an aircraft unaccompanied. And anyone who encourages staff not to raise them shouldn’t be in employment. There, MoD’s personnel problems in a nutshell!

FantomZorbin

23rd Jan 2017, 07:04

RetiredBA/BY #222
It was the RAF Wyton Station Commander I believe, an ex OC 100Sqn

Bob Viking

23rd Jan 2017, 07:26

Wander00

23rd Jan 2017, 09:11

FZ - It was - I was ( a very new) OC Admin there at the time. Tragic accident

LOONRAT

16th Feb 2017, 16:10

Heard court case now scheduled for 17 May 17.

Dominator2

16th Feb 2017, 17:23

BV, I started fast jet flying a couple of years before BEagle and from 75 onwards flew 6000 hours on zero/zero ejection seats. If my memory serves me correctly we used the simple principle that if the canopy was down we were strapped in and seats live. If the canopy/canopies were open we were seat safe and unstrapped. On any bang seat it is implicit that the occupant makes the seat SAFE at a time when it can be ensured SAFELY. If it was essential to taxi back with the canopy open (due to excess temperatures) then we stopped for 15 seconds and safed up the seat safely. Yes, and for you younger ones we used to fly jets that did not have AirCon and cockpit temperature could reach 50°C+

Just This Once...

16th Feb 2017, 17:35

Indeed, it must have been positively chilly back in the day. The younger ones will have flown aircraft still without conditioning on the ground, lacking a canopy that could be opened for taxi and temperatures knocking on 50°C just walking out to the aircraft.

But yes, your point is well made - some of the 'norms' that crept in with pins, seat safety and checks did not help matters at all.

Pure Pursuit

16th Feb 2017, 19:01

Beagle, D2,

Perhaps SOPs change. I've only ever had back seat trips so, I'm only talking from the perspective of a pax. I have always, on every single trip, been told to put both pins back in as we taxied back. Surely, unstrapping and hoofing it to safety is a better option than pulling the handle!

If it's folly to do so prior to engine shut down Beagle, I'd suggest that the current Hawk community disagree with you.

Just This Once...

16th Feb 2017, 20:39

On the Tornado we would remove and stow all pins apart from the SPFH on crew-in. The 'live' canopy was lowered shortly after start, with the groundcrew hiding underneath. We would taxi out for a short distance before the remove, show and stow of the seat pins. Seat and canopy pins would be reinserted on the taxi back so that everything would be safe for the winch-back.

m0nkfish

16th Feb 2017, 21:37

As far as I'm concerned, if you fly single seat then its your life and therefore your decision. I was always more comfortable being unstrapped on the taxi back and would justify that by saying it was quicker to egress if there was some kind of problem, but then again I didn't taxi out unstrapped.

In a two seat jet its a crew decision. Of course, when the canopy is down its not always appropriate to arm seats as the aircraft may be in a HAS or shelter.

Aircrew are clever people and spend years in training and IMHO are treated like children now by an organisation that seems to want to have a rule and procedure for everything.

dervish

17th Feb 2017, 12:18

rule and procedure for everything.

What comes first, the design or the rules/procedures for using that design? "We've always done it that way" might not be valid if the design changes.

Chugalug2

18th Feb 2017, 08:54

Quite agree, dervish. I have no problem accepting that "pin procedure" has evolved greatly since I first perched tentatively on an MB Mk3P. As you say, technology moves on, designs change, rules and procedures adapt and change accordingly. The point is that in a disciplined environment that is forever trying to make you fondly remembered, you stick to the rules.

The worst thing is when the rules are changed or simply scrapped, not to protect life but money, and short term money at that. There we move away from the cockpit to the murky corridors of power, from JOs to VSOs. That is where Sean Cunningham's fatal accident was conceived, that is where the system designed to safeguard his life became the one that killed him. That is where the court should be directed.

m0nkfish

18th Feb 2017, 15:07

What comes first, the design or the rules/procedures for using that design? "We've always done it that way" might not be valid if the design changes.

I didn't mention design because it's hasn't fundamentally changed in years yet the rules and procedures seem to grow and grow until the point people are not quite sure why they are even there.

My point related to the practice of unstrapping from an ejector seat during taxi back. Something that was stopped with (IMHO) no real justification other than to satisfy the desire to be seen to be doing something.

dervish

19th Feb 2017, 12:15

mOnkfish

Thanks, and I agree. But it could be inferred that SOMETHING has changed, because there was once a valid safety case, and now there isn't!

RetiredBA/BY

19th Feb 2017, 14:08

I first started flying aircraft with zero/zero bang seats in 2002. At least as far back as that we have been replacing pins on the taxi back. Indeed in certain aircraft we would fully unstrap and have the canopy open.

Should there be a fire the safest thing may be to shut the aircraft down and climb out.

You may now be horrified to hear this but consider how many uncontained engine fires there have been on the ground in this period (none that I am aware of). There have been several rapid egresses though where having the seat safe will have speeded (is this a word?!) up the process and made it more safe.

There have been procedural changes since Sean's accident but I won't go into them here. Please don't shoot the messenger.

BV:O
I am very curious to discover why crews were unstrapping during taxi back. During ALL of my time on ejection seats, 12 years, I never, ever, saw anyone unstrapping, or even attempting such before shutdown and as a refresher QFI I flew with a LOT of very experience students, from P/O to AM. ( Perhaps some easing of shoulder harnesses but nothing more.)

Similarly in my 25 years on civil jets never ever saw any pilot fully unstrap during taxi in.
Shoulder straps, perhaps but never a full unstrap.

What do you "unstrappers" now know that the rest of us did not ?

m0nkfish

19th Feb 2017, 14:31

I am very curious to discover why crews were unstrapping during taxi back. During ALL of my time on ejection seats, 12 years, I never, ever, saw anyone unstrapping, or even attempting such before shutdown and as a refresher QFI I flew with a LOT of very experience students, from P/O to AM. ( Perhaps some easing of shoulder harnesses but nothing more.)

Similarly in my 25 years on civil jets never ever saw any pilot fully unstrap during taxi in.
Shoulder straps, perhaps but never a full unstrap.

What do you "unstrappers" now know that the rest of us did not ?

I am surprised you never observed the practise of unstrapping on taxiing back. I flew with three different air forces and found it a very common occurrence.

There are arguments both for and against but nothing that can apparently definitively lay the matter to rest.

I believe this should have been left up to the individuals to make their own informed decisions and did not need further regulating, but it seems now that you have to be seen to be doing something, etc, etc

nipva

19th Feb 2017, 15:23

I think that you will find that the practice was not that uncommon on the older 90kts S & L seats where ejection was not an option at taxy speeds. After an hour plus of being tightly strapped in to a seat that had no compromises to comfort, it was often a merciful release to be able to restore feeling to one's nether regions. Loosening off shoulder straps just didn't do it. So, on clearing the R/W it was pins in often followed by various levels of unstrap

Chugalug2

19th Feb 2017, 22:13

m0nkfish:-
I believe this should have been left up to the individuals to make their own informed decisions and did not need further regulating,

As a matter of interest, has the instruction to disarm only after shutdown come from the regulator (ie the MAA) or from the operator (standardisation flight etc)? Either way I am surprised that you think it should be left to each individual pilot or crew, as the case may be, to decide for themselves whether to disarm or not while taxiing in. What about the ground crew receiving an aircraft, not knowing if it is armed or disarmed? What about the crash crews not knowing if an aircraft that has been abandoned on a taxiway (on fire?) is armed or disarmed?

As I've said before, I don't pretend to understand the pros or cons of which is the best procedure for modern zero zero seats, but I'm pretty sure that once the procedure is set then it should be adhered to, if for no other reason that everybody knows what to expect.

In any case, aren't we straying somewhat from the thread OP? MBA (and not the MOD!) are being prosecuted over the death of Sean Cunningham it says. Given the interesting stat posted by tucumseh in post #231:-

In the early 1990s, funding to do this was cut by 28% per year, for over 3 years. Direct orders were issued not to use the MF765 (or MF760 fault reporting) systems – part of the “savings at the expense of safety” confirmed by Mr Haddon-Cave; although he dated them to 1998, not 1987, despite the actual documents and directives being submitted to him. There, systemic airworthiness failings in a nutshell.
While some of this work has been resurrected, by no means all – evidenced by the much abbreviated definition of it in the MAA documentation.

So a 28% cut every year for over three years. Just think about that one. This to a system that is one requiring a process of continuous uninterrupted auditing. UK Military Air Safety was killed stone dead by that. It has never recovered. This seat had no Safety Case Report. It was unairworthy. The aircraft was therefore unairworthy. What the hell was the regulator doing? If your only quibble is that it has messed you around simply to be seen doing something you have my sympathy, but I would expect it to be doing its job, which is to ensure the airworthiness of HM aircraft. It has singularly failed in that.