May I try to offer some background and analysis here, particularly on the findings of the MAA report...As Tuc observes, something is going on here. The HSE intend to prosecute Martin Baker, not the MoD or the RAF. However, the MAA's report doesn't contain much that would obviously 'hang' MB. But as for the MoD and the RAF...here's my take.
Firstly a bit of data. MAA reports define their accident factors via the following categories, in descending order:
Cause - the event that led directly to the accident
Contributory - Factors that directly or indirectly made the accident more likely
Aggravating - Factors that made the outcome of the accident worse
Other - None of the above, but could cause, contribute or aggravate a FUTURE accident
Observations - factors not relevant to the accident but worthy of consideration to promote better working practices
So, trawling thought the report, here is my summary of what the MAA came up with. I've focussed on the technical aspects that might affect any MB liability. Caps used for clarity.
1. The MAA found that the CAUSE of the accident was the inadvertent ejection due to displacement of the seat pan handle. Various CONTRIBUTORY factors were identified around the SPH design and use in service, also strap positions.
2. The reason that the pilot died was the failure of his parachute to deploy, due to an overtightened drogue shackle. This risk was known to some in MB, but not, apparently, to the MoD. The MAA found that 'Poor communication between stakeholders and the lack of a robust system of tracking amendments..(which) restricted the flow of safety critical information' was an AGGRAVATING factor. They also found that the shackle dimensions, combined with extant MoD guidance on nut fitment led to an interference fit. Shackle dimensions were thus judged an AGGRAVATING factor.
3. The reason that the shackle had been overtightened was RTI/Hawk/059D, which required the shackle to be disassembled every 50 flying hours to allow an NDT examination of a potentially cracked seat beam. The report reveals that although MB recommended a 14 day visual inspection, and 1710 NAS confirmed that the seat would be safe with a cracked beam, 22Gp decided that operating as such would 'undermine aircrew confidence', and so an NDT inspection was introduced. However, the report reveals 'the absence of a clear audit trail, poor Hazard Log tracking and a paucity of decisional meeting records', so MAA could find no rationale for this decision. This was stated to be an OTHER FACTOR. However, the (quite astonishing) lack of any safety case for the seat, while mentioned, is not identified as any sort of factor. If you don't have a safety case, it's not possible to conduct a proper hazard analysis of any proposed servicing change - like an RTI that regularly takes the drogue shackle apart.
4. The report makes it clear that once the original problem (seat cracking) was found MB and the technical specialists worked hard to get a mitigation out there. But, quite amazingly, the report doesn't comment on why an RTI was being used when an STI (required when MB was involved) should have been issued.
5. Finally, the report shows that RAFAT (Reds') engineering standards were not up to the mark as far as seat maintenance was concerned. Signatory and supervisory malpractices were considered to an OTHER factor, while absence of compliant engineer training was a CONTRIBUTORY factor. (Bear in mind that to compress the shackle, the maintainer had to cut new threads on the shackle bolt - this is definitely NOT good practice).
My thoughts - and with the usual warning that I am entering 'opinion' territory. The first thing that astonished me was why anybody would imagine that taking a seat shackle apart, in the aircraft, every 50 flying hours, was a safe thing to do. In all my years around jets, any work on a seat, especially the operating mechanisms, required a seat lift and return of the seat to the seat shop. The second thing was the absolute horlicks that happened between the HSA, the AES PT and 22 Gp in the development of the RTI. Who, in the name of all that is holy, thought that 'aircrew confidence' justified taking the risks involved in dismantling the escape system? Where was the RTI file? Where was the hazard log entry management? Where were the records of decisions? WTF?
I honestly don't buy the MAA's analysis. Here's my stab:
1. If the shackle had worked, this would have (very probably) been an incident, with the pilot surviving. It became an accident because he died. He died because his parachute didn't deploy. It failed to do so because the drogue shackle had been disassembled and on reassembly overtightened to such a degree that it jammed. The jammed shackle was, in my view, the CAUSE. The inadvertent operation of the SPH was a CONTRIBUTORY factor. (But see below)
2. The only reason the shackle had been disassembled was the RTI. I see the failure to issue a satisfactory STI as the main CONTRIBUTORY factor.
3. Lack of a safety case and a proper system for developing the STI were AGGRAVATING factors.
4. The shackle was overtightened because the information available to the maintainer wasn't complete. And the maintainer wasn't properly trained to do this job. Those, in my view, are also AGGRAVATING factors.
So, where would this leave MB? The worst that they appear to be on the hook for is not getting a certain piece of technical information out to the MoD, which may have been an aggravating factor. Or more probably, the seat pan handle design. Again, the lack of a safety case, which would have highlighted the hazard and shown the mitigations, is a key factor. In my view, the MoD and the RAF are a good bit further up the chain of responsibility here. The Reds' maintainers didn't do a great job, but they were really put in a bad place by a series of failures higher up the chain. Including systemic failures in the airworthiness management systems in the MoD and the RAF.
OK, I'm done, and apologies for the long post. Any thoughts out there?
Best regards as ever to those keeping things safe,
Engines
Last edited by Engines; 26th Sep 2016 at 19:29.