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Old 1st Nov 2021, 18:10
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Lordflasheart
 
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Risk Assessment and Duty of Care

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Risk Assessment and Duty of Care - Big Cheese Holes and the Big Cheese


Corporal Bayliss should not have died. His death was wholly avoidable. Under the circumstances, he didn't stand a chance.

From the SI - He did not receive some of the listed training expected for newly selected circus members which elevated the risk. Such that the SI recommended the DDH should mandate a formal training syllabus. Under the circumstances, that issue probably made little or no difference to the fatal outcome.

From the SI - The pilot was distracted by certain issues beyond his control, including a simulator ride at Valley between flights, being required to carry out flight manoeuvres that arguably were incompatible with a shakedown flight for a prospective circus member, misjudging the flight path, losing control and ejecting. Under the circumstances, those 'overwork' issues probably made no practical difference to the fatal outcome.

The path leading to Jon Bayliss' death was laid down many years earlier. Someone would eventually come to grief.

The foundation was the systemic, blind belief that the risk involved in routine and frequent carriage of any non-aircrew in the back seat of a Hawk T1 (especially with the elevated risk associated with certain flight activities) could be passed off as Low and Tolerable and ALARP.

In principle, it's a little bit like building V-Bombers, where only certain crew members were provided with ejection seats. Was the risk deemed to be Tolerable and ALARP or whatever it was called in those days ? Or was it passed off as "Rien ne peut être fait. C'est la guerre froide" ?

Many relatively minor shortcomings in technical and training records, administration and oversight were listed in the XX 204 SI. More serious shortcomings were identified in the SI for XX177 (like absence of a valid Safety Case and the length of time taken to locate and obtain important documents from the multitude of agencies with fingers in the Hawk Pie. Similar issues for other Hawk crashes. And as regularly mentioned and warned, even to the NW Wales Coroner, a long list of serially ignored recommendations, while lying to successive inquests, inquiries, courts etc., that 'lessons have been learned and all recommendations have been implemented.'

Among all the fancy risk assessment data, including as shown in the risk register at the time of XX177 ten years ago, and doubtless up to XX204 in 2018, I could find nothing that discussed or questioned the fundamental issue of why any passenger or supernumerary crew member must be seated in the back (as opposed to anywhere else.) Nothing even to suggest that the seat-specific risk had been considered or had achieved the magic words 'Low and Tolerable and ALARP.'

Everyone in the Hawk and Red Arrows world should know about the command ejection system as fitted to the Hawk T1. Hawk T1 was designed as a trainer, where the command pilot ie the Instructor, would be the GiB, and command ejection could only be initiated 'from the back.' If the command pilot is in the front (as for most Hawk T1s these days, command ejection must be switched off. You can't currently switch 'command' from back to front. Neither can you allow an unqualified back seater the ability to initiate ejection for both seats.

That leaves the back seater to make his/her own 'in extremis' decision to eject, whether ordered or not. What happens when the front seat command pilot of a doomed Hawk T1 shouts "Eject ! Eject ! Eject !" and the back seater doesn't go ? .... How long would you give it ?

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Why did this specific risk assessment (if any) apparently stop where it did ?

With XX204, the SI begins to open up that discussion at last.

Recommendation 1.5.6 Page 1.5 - 2

f ) "RAFAT DDH should ensure that Circus are only employed as Supernumerary Crew on sorties that are directly associated with their primary role and not exposed to potentially hazardous flight profiles .... "

Analysis conclusion 1.4.477. Page 103

"... "Simulations indicated that if a front seat-initiated command eject system had been in place then both individuals might have vacated the aircraft before ground impact."

1.4.482. Two Aggravating Factors. (page 103)

a. The engineer's lack of experience to independently initiate his own ejection.

b. The lack of a front seat-initiated Command Ejection system.

1.5.2 Recommendations - "AOC 22 Gp should ....

e. Assess the feasibility of the incorporation of a command eject capability into the Hawk T Mk1 that would allow aircraft commanders to initiate the ejection for occupants from either cockpit seat."

And from the Convening Authority Comments - dated April 2019

NB The Convening Authority DG DSA post holder in March 2018 was Maj Gen Felton. Since March 2019, DG DSA is AM Gray. I have no knowledge of which DG wrote the comments to SI XX204. Bear in mind the comments were written when it was believed Hawk Mk 1 would be in service until 2030. You can see how the landscape might be changing ...

1.6.11. " ... The rationale for engineers to be Supernumerary Crew and deliver engineering support away from RAF Scampton is clear. Nevertheless, their employment in such a capacity should only be on sorties that are directly related to their primary role."

1.6.12. "... With aircraft commanders in all 3 main Hawk T Mk1 squadrons predominately occupying the front cockpit seat, it is appropriate to assess the feasibility of a command eject capability that could also be initiated from that position. Alternatively, Defence may have to assess if the risks associated with carrying passengers in the rear cockpit of the Hawk T Mk1 are tolerable.

Two years later the Defence Command Paper announced the surprise premature retirement of C-130, BAe146, Typhoon Tranche 1, E-3D Sentry and Hawk T1. In the latter three cases a clear about face from fairly recent positive statements on out-of-service dates and arguably, for all five types, resulting in an unwelcome capability gap. Perhaps Hawk T1 is going early because MoD refuses to pay for any general mitigation. Has RAFAT managed to head off any big changes to current Circus procedures ?
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I seems to me entirely possible that the new DG DSA has had time to review a number of safety matters and has found them wanting. Furthermore it is entirely possible she has done what her predecessors seem to have avoided, grasped the nettle and tried to rope the sacred cow. .... Consider this -

"... Alternatively, [ without front seat command ejection] Defence may have to assess if the risks associated with carrying passengers in the rear cockpit of the Hawk T Mk1 are tolerable."

As it stands, a proper assessment of risk to life and duty of care for Hawk T1 rear seat passengers, could not possibly justify a claim of Low and Tolerable and ALARP. ... Jon Bayliss' death seems to support that argument. You would have to look further for an acceptable safety assurance.

If Circus has to travel, why not in the front seat ? If that is unacceptable to RAFAT, rather than pandering to the sacred cow, declare that it is equally unacceptable to continue with the current arrangements and another safer mode of travel will have to be found. Perhaps that discussion has already taken place. If so, what was the outcome ?

Other notable national aerobatic teams use support air transport as a matter of course, albeit many because their aircraft are single seaters. MoD knows this well because last year they sold a spare C-130J to the US Navy for their Blue Angels, (to be flown by the USMC in pretty Blue Angels colours and Marine Corps markings.

MoD has several C-130s and BAe146s for disposal. Re-cycling one or two of these might be cheaper in the long run than having a more expensive repeat of XX204.

However, there is no public indication (since 2018 and even now) that anything has actually changed (or is about to change) in terms of Red Arrows Circus seating or command ejection or alternative travel arrangements.

If no change is envisaged, that would be to publicly abandon any pretence of safety concern for this particular issue. That might suggest that DG DSA has either followed the laissez-faire or lost the battle.

If I were the NW Wales Coroner, in the Public Interest I would declare the Bayliss inquest to be Article 2. I would also summon the DG DSA, the Big Cheese herself, who might even welcome the opportunity to spill the beans in public, though it might put a damper on her career.

Jon Bayliss should not have died. His death was wholly avoidable. Under the circumstances, he didn't stand a chance.

Immediate Action to prevent a repeat would deliver a measure of justice for his family and for his memory, and would clearly be in The Public Interest.

Who Speaks for the Dead ?

LFH
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Last edited by Lordflasheart; 1st Nov 2021 at 18:33. Reason: speling
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