PPRuNe Forums - View Single Post - Flt. Lt. Sean Cunningham inquest
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Old 28th Feb 2014, 09:43
  #686 (permalink)  
Engines
 
Join Date: Dec 2006
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Chug,

I think I have to gently differ from you in what is probably a minor matter.In any case, I post this only to attempt to help others through the issues.

First, I agree with other posts that getting into semantics over the various factors that led to this tragic accident aren't especially helpful. Like almost all such events, there was a chain of causes and events and the SI's job was to find all the links in that chain and set out recommendations to prevent re-occurrence.

I think the technical investigation into the seat aspects was well done, and it's good to see the capability of the old NAML (Naval Aircraft Materials Laboratory - now 1710 NAS) and the professionalism of the old RN AIU (the cornerstone of the new MilAAIB) still delivering good results. The fact that they got 'folded' into the MAA following Haddon Cave wasn't their fault - and I very much agree that having them there is a basic mistake. However, i would gently offer that calling them a 'chocolate fireguard' is just a bit strong. I'm sure that they are doing the best they can within the organisation that they were given to work with. In fact, I know they are.

As I've posted, my own opinion is that the format adopted by the MAA for reports makes it harder for them to be clearly understood and acted upon. In this case, the technical factors were reasonably clear, but the organisational aspects were less clearly established. And that brings up to the issue of how far up the chain the SI can go in looking at the 'organisational' stuff. I agree with Tuc that the SI should have found out why the aircraft's Safety Case was so badly compromised. It should also have established why the airworthiness trail for the RTI (which is supposed to be auditable) was so thin.

But I don't think that any SI is going to be able to go back tens of years and look at funding and policy decisions by VSOs that contributed to the present situation. My own view is that the MoD has to be responsible, at all levels, for managing and preserving 'Air Safety', which includes airworthiness. That means people have to do their job. The basics haven't changed. What does bother me is that a number of managers within the system no longer have a clear idea of what 'the basics' involve.

Best Regards as ever to all those working the issues,

Engines
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