Folks,
I've purposely stayed clear of this thread until now - there have been some very well informed posts here, and I felt I didn't have much to add of value, until now. I hope this contribution may help, or help the exchange of views.
The SI report is not an easy or consistent read. I think (but don't know for certain) there may two reasons for this:
1. Redaction or moderation of comments which reviewers felt may have not agreed with. Motives unknown, but could range from correction of fact to desire to preserve reputations of individuals or organisations. I'm sorry, but I suspect the latter. I wish I didn't.
2. Less speculative - the change of role of the accident investigators. When the AAIB was still the RN AIU, its involvement in SIs was ordered by the RN's Advisor of Aircraft Accidents based on the initial accident report. It's remit was to carry out a technical investigation, and it delivered a separate and complete report to the BoI's president. BoIs were normally adjourned while the AIU did that. The BoI then reconvened, and considered the AIU report as evidence.
Now, the AAIB has been integrated within the SI process, and its investigation is mandated to support the SI as directed. Other posts have commented on the potential problems with this, and I very much agree that having the Accident investigators under the command of the regulatory authority is not the right arrangement to help improve Air Safety. It also leads to reports which combine the technical narrative with the wider organisational aspects, and like others, I found some of these latter paragraphs short on fact and long on opinion.
Looking at the technical issues, I am struck by the role played by RTI/Hawk/059D. In my opinion (and that's all it is) the reason a fatality occurred was the failure of the shackle to release, and that was down to the malpractice that took place during execution of that RTI. The report covers the background to the RTI, but I am surprised by the statement that the AOA did not want to operate aircraft with a cracked cross beam, and probably insisted on the frequent inspection, 'as the visual affect (sic) may undermine aircrew confidence in the system'.
No, check that - i'm astonished. The way the aircrew have confidence in the system they are given to fly is by inspecting and signing the F700. Engineers decide what is acceptable and what isn't up to that point. The day you start managing aircraft maintenance to bolster 'aircrew confidence' you are hazarding safety. And I honestly think that's what happened here.
My years with and around seats and escape systems were relatively uneventful. One reason for that was that the RN operated a system where maintenance on seats on aircraft was intentionally restricted to seat removal and installation - the RN operated a system of 30 week bay servicing, where experienced (civilian mostly) fitters did the work. At sea, a very limited bay servicing facility was provided, but the ship usually carried a couple of spare seats. There was a deliberate policy not to fettle seats while they were in the aircraft.
I'd like to know who came to the conclusion that taking the drogue and scissor shackles apart every 50 flying hours on aircraft wasn't a safety risk. And why they carried on doing intrusive NDT inspections when 1710 had told them they weren't required. Oh, and why they didn't stick to a non-intrusive visual inspection to begin with. OK, I don't have the detail to hand, I could well be off beam here. But neither did the SI, due to lack of records. Bad. The old ES(Air) 'Annex A' and 'Annex B' systems would have provided those records.
Given all that, I am surprised (very) that the introduction of the RTI, and the way it was carried out, weren't cited as at least an 'aggravating' factor. I'm also frankly staggered, given my experience of the RAF's very thorough and complex authorisation systems, of the findings into RAFAT engineering personnel's lack of training and qualification to service seats. I don't like saying this, but I hope the SEnGO involved is now doing something a long way away from aircraft maintenance management.
As Tuc and others so rightly say, all that is really required (on the technical side) is for everyone at the sharp end, and in the EA areas, to do their damned job in accordance with basic engineering principles. Don't look to the regulator to make it all better - they just write regulations. Don't look to VSOs to sort it out - most of them aren't engineers.
Final point. The saddest part of this report is the long list of recommendations, most of which boil down to 'do what you are supposed to do'. That hasn't happened, and there needs to be some serious heart searching as to why. Building a huge and complex regulatory set is OK, as long as the system being regulated has the means of compliance. I don't think, in this case, it had.
Best regards as ever to all those affected by this,
Engines