JTO
I, too, am with Sqn Ldr Turner on this one. The SI report details some poor lapses at RAFAT but what it actually describes is very serious and criminal SYSTEMIC and ORGANISATIONAL failures. Same as all the other cases we discuss here.
The way it is written is appalling. But, like many such reports, the feeling is there was much more and it has been heavily edited. You know, because MoD doesn't ensure it is consistent and makes sense, post-edit. (See ZD576 - we've been here before). Like many reports, it presents uninformed personal opinions as fact, while ignoring demonstrable fact. (See XV650/704 - we've been here before....).
The purpose of the SI is to identify causes and help prevent recurrence, but there is absolutely no depth to the engineering investigation whatsoever. It may look like there is; lots of diagrams of nuts, bolts and shackles, but this is basic, first year apprentice stuff. Pilots may topple or even be impressed, but engineers cringe. But if you list all the components of the process involved in ensuring that seat is safe, and used safely, then it barely touches most of them. I've said before, part of the reason is because MoD simply don't "do" this discipline anymore. 20 years after the Chinook safety case warning, which developed after the RAF Chief Engineer stopped such work, here we are with a safety critical system with no safety case. That is not the fault of RAFAT in any way, yet it is THE major failing because it is so fundamental everything else is affected. In case the MAA claim they haven't had enough time to correct this, the more recent Nimrod case was not a revelation, it was wholly predicted and advised to senior staffs and Ministers repeatedly over that 20 year period. The MAA INHERITED 20 years of very detailed and precise warnings, which time after time have been proven absolutely correct. But they say their clock started when they were formed, as if Haddon-Cave was a surprise. All he did was collate 20 years worth of recommendations, which were sat on the desks of various 3 and 4 Stars.
Regarding the laughably incompetent and criminal lack of a seat safety case. Having discovered that (well done the SI; it is the obvious question but so few ask it) then a significant portion of the report should have been aimed at WHY. Instead, it just moves on as if it is insignificant. I wonder if this part was edited by the MAA? The report recommends more and better training for junior ranks, but completely fails to address the BIG one. Who made a false declaration when signing the Releases to Service for multiple platforms (not just Hawk) to the effect he was satisfied the Safety Case audit trail was complete and valid? Are those Stars, and those who briefed them, competent? Do THEY need retraining? Or trained in the first place? In other words, juniors are crucified but, YET AGAIN, senior staffs are not mentioned.
It rightly mentions RAFAT failures, but in my opinion dwells on them and draws the readers attention away from the organisational and systemic stuff. That is, it actively protects the senior staffs who KNOWINGLY allowed this to happen. Can we trust the MAA to correct this? Not a chance. They haven't bothered until now. Why? They're part of the problem because they dare not criticise their own MoD seniors. Which contrasts with Sqn Ldr Turner's brave statement (even if unguarded).
I wonder if Wg Cdr Spry has anything to say? Or is he still grappling with the concept of functional safety? This was a functional safety failure, but not according to Spry's definition. Come on, buck up, people are dying.