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Old 27th Sep 2016, 16:34   #61 (permalink)
 
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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!
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Old 27th Sep 2016, 16:34   #62 (permalink)
 
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Originally Posted by NutLoose View Post
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..
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Old 27th Sep 2016, 16:43   #63 (permalink)
 
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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?

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Old 27th Sep 2016, 16:46   #64 (permalink)
 
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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.

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Old 27th Sep 2016, 16:48   #65 (permalink)
 
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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.
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Old 27th Sep 2016, 16:54   #66 (permalink)
 
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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.
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Old 27th Sep 2016, 18:34   #67 (permalink)


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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.
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Old 27th Sep 2016, 18:42   #68 (permalink)
 
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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...

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Old 27th Sep 2016, 18:59   #69 (permalink)
 
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Originally Posted by EAP86 View Post
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
Well indeed. If that does impinge on this case then it would probably be classified by safety engineering specialists as an "organisational accident".

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Old 27th Sep 2016, 20:08   #70 (permalink)
 
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Excellent analysis, thanks.
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Old 27th Sep 2016, 20:11   #71 (permalink)
 
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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.

Last edited by NutLoose; 27th Sep 2016 at 20:24.
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Old 27th Sep 2016, 20:24   #72 (permalink)
 
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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.
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Old 27th Sep 2016, 20:31   #73 (permalink)
 
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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.

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Old 27th Sep 2016, 20:38   #74 (permalink)
 
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Judge, jury and executioner. Case closed.

BV
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Old 28th Sep 2016, 04:26   #75 (permalink)


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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.
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Old 28th Sep 2016, 04:36   #76 (permalink)
 
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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.

Quote:
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.

Last edited by tucumseh; 28th Sep 2016 at 05:24.
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Old 28th Sep 2016, 08:00   #77 (permalink)
 
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tuc:-
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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.
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Old 28th Sep 2016, 08:17   #78 (permalink)
 
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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.
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Old 28th Sep 2016, 09:09   #79 (permalink)
 
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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
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Old 28th Sep 2016, 09:56   #80 (permalink)
 
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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.
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