Flt. Lt. Sean Cunningham inquest

[cockney steve]

RE- TUCUMSEH's post above...
Any "training system" that is not fully documented, is fundamentally flawed. Especially-so in a Military where it is a given that the grunts on the ground will have a relatively short carreer span......so what a bloody brilliant idea, hey, -let's go back to the industrial revolution, nothing written down, all knowledge passed by word of mouth.....for those a bit lacking in History, Caxton's printing press opened-up the "Craftsman's Clubs" once the peasants could read, they could learn skills easily and cheaply. (Mastering them, was another issue.......
here we were , in the 20 th. century, relying on an instructor's memory to tell a new load of "oiks" everything . The half-baked "constant amendment and update" protocol that TUC. referred to, was fatally flawed.
the comprehensive "Old-School" knowledge was pushed out of the door by MOD bean-counters.
Their chickens have come home to roost.

A proper service and maintenance manual should detail exactly what maintenance and repair operations should be carried out, when, and most importantly how
As kit becomes obsolete, new manuals and procedures are needed, It's a continuous , evolving process.

From what I've read here, seems the MOD cut off any proper support to the fixers...perhaps they thought the odd death , like Mr. Cunningham's , would be cheaper.
I do hope the Coroner has the initiative to look behind the MOD's shameful curtain .

[tucumseh]

cockney steve

Thank you. You are absolutely right.

Could I just clarify that the "bean counters" who chopped the funding (i.e. made savings at the expense of safety) are well known and were named in evidence to both Haddon-Cave and Lord Philip; evidence made irrefutable because it included their directives from June 1987 to June 1993. Almost to a man they were Air Rank officers. Even MoD have now chosen not to challenge this historical fact.


I predict, like the Nimrod and Chinook Reviews, the recommendations will be replaceable with "Implement mandated policy".

[Chugalug2]

CS:_
Their chickens have come home to roost.Only for the victims I'm afraid. Those who initiated and perpetuated the sabotage of UK Military Air Safety remain unscathed, their reputations unsullied. In stark contrast the families and loved ones of those who perished in Airworthiness Related Fatal Military Air Accidents have a lifetime sentence of grief imposed upon them.


The pity of it is that there appears to be no institution or organisation in the land that is professional enough, powerful enough, or cares enough to challenge the lies and obfuscations of the MOD and the Star Chamber (both serving and retired).


One yearns for such a professional body to bring them to account, to highlight the illegal orders and the suborning of the Regulations that resulted. In short one yearns for a truly independent Military Airworthiness Authority and a Military Air Accident Investigator, when all we have are the MAA and the MAAIB. Unless and until they are made independent of the MOD and of each other, we must depend on an 800 year old institution to tell one that is less than 100 years old, "There is something wrong with your bloody aircraft!".

[NutLoose]

A proper service and maintenance manual should detail exactly what maintenance and repair operations should be carried out, when, and most importantly how


True, but welcome to the Civi world, I have copied a section out of a current manual for you..



INSTALLATION.
Before installing the engine on the aircraft, install any items which were
removed from the engine or aircraft after the engine was removed

Fine if you actually took it out and the muppet prior to you didn't just write engine removed, accessories removed, engine sent for overhaul. ...

[Croqueteer]

Was Sean Cunningham's father, Jim, an AEop on Shackletons?

[NutLoose]

News and Events (http://www.martin-baker.com/news-and-events)

[SirPeterHardingsLovechild]

Recording a narrative verdict, Coroner Stuart Fisher said the safety pin mechanism was "entirely useless" and said the pin's presence was "likely to mislead".


Is anyone else in PPRuNe-land uncomfortable with this? "Flawed" and "possible to mislead" would be a more responsible thing to say (from a respected 800 year old institution)


This leads to Flt Lt Cunningham's Dad saying


"We welcome the conclusion of the coroner which confirmed what we knew all along, which is that Sean was blameless and his tragic death was preventable"


With the greatest of respect, sir. By any measure, and on at least 2 key points, Sean shares some of the blame.


It is a very serious matter to blame the MoD & MB, when it is clear that complacency, and plain bad luck had a large part to play here. MB statistics alone point to this.


I've got this 'orrible feeling I'm taking the attitude of the Mull of Kintyre Airships here. But I see that the family accepted a settlement in Dec '13 so this one in done & dusted...waiting for the BoI report

[Distant Voice]

I assume that the SI report will confirm that on examining the seat after firing,

(1) The seat safety pin was still in the hole but not engaging the firing handle.

(2) The "nut and bolt" displayed more than one and half thread turns, which was consistant with over tighening.

(3) The date of the last servicing and the publication used.

DV

[Chugalug2]

SPHL:-
and plain bad luck had a large part to play here.The bad luck seems to have been that this aircraft had an escape system that was "entirely useless". Other than something on which a pilot could park his backside the rest of it was so much dead weight, and as it turned out very dangerous deadweight at that. Because of that the aircraft was as unairworthy as the Mull Chinook, the Iraq Tornado, the Afghanistan Nimrod, etc. There is the same common thread linking those tragedies with this one, ie a dysfunctional UK military airworthiness provision system.


As you say, let us see if the SI Report reveals that, and if so why that was. Or not...


the family accepted a settlement in Dec '13 so this one in done & dustedA new MOD tactic to settle before both inquest and SI publication? Now why would they do that I wonder?

[5 Forward 6 Back]

I can't be the only ex- or current Hawk pilot who thinks that branding the entire escape system "entirely useless" simply isn't true. It's saved a few of my friends!

You could put the pin somewhere if the handle was half-pulled. You could also miss the hole and jam it in by the side of the handle. That's why we were always taught, even as Hawk students, to physically check it, and look to make sure it was correctly located.

The system was flawed in the sense that you could put the pin somewhere that didn't make the seat safe. That doesn't mean the whole system was suddenly "entirely useless."

[Wrathmonk]

5F6B

Doesn't matter where the seat pin is or isn't if the scissor shackle has been over tightened.

[P6 Driver]

Any ejection seat could be described as "entirely useless" if it hasn't been maintained or assembled correctly, to ensure that all aspects of its operation would be efficient and safe. This particular seat was, with hindsight, useless.

I'd be interested to know how many other Type 10 series seats were examined in the days after this accident and found to have the same fault with the Scissor Shackle unit.

[Top West 50]

Anybody got an answer for RetiredBA/BY?

[tucumseh]

I've got this 'orrible feeling I'm taking the attitude of the Mull of Kintyre Airships here.

No, as far as I can see you've done nothing that warrants imprisonment under the Air Force Act. They, however.......

[Background Noise]

I don't think he branded the entire escape system was 'utterly useless', just the 'safety pin mechanism' - which has been shown (sometimes) not to render the system safe, even when fitted (albeit incorrectly).

However, the pin usefulness is a slight red herring as the pin would have been removed and stowed by that stage - as mentioned previously.

The significance of 'likely to mislead' is that anyone seeing the pin fitted (albeit incorrectly) would assume that the handle was fully in and therefore fairly safe. It has been shown that it can in fact be partially dislodged and in a fairly precarious condition.

[EGLD]

FWIW, I believe the seat would've worked in an in-flight ejection due to the stresses on the chute overcoming the pinching effect of the restraint that was over-tightened, so the escape mechanism wasn't entirely useless, only in this unfortunate situation of zero-zero

Did anyone state what the reason was for the seat firing? i.e. what triggered it?

[NutLoose]

Wrathmonk

Join Date: Feb 2006
Location: UK
Posts: 1,054
5F6B

Doesn't matter where the seat pin is or isn't if the scissor shackle has been over tightened.



That would depend entirely on altitude, if it ejected at height, wouldn't he still have manual separation to fall back on?

[EGLD]

To try and answer my own question, is this suggesting that the pilots straps had been passed through the firing handle, which could be the trigger for the seat to fire?

Sean Cunningham inquest: A catalogue of errors led to pilot's death, coroner concludes | Lincolnshire Echo (http://www.lincolnshireecho.co.uk/Sean-Cunningham-inquest-catalogue-errors-led-Red/story-20520370-detail/story.html)

The court heard that Martin-Baker has been looking at some sort of shroud to prevent straps from being fed through the seat firing handle.

Read more: Sean Cunningham inquest: A catalogue of errors led to pilot's death, coroner concludes | Lincolnshire Echo (http://www.lincolnshireecho.co.uk/Sean-Cunningham-inquest-catalogue-errors-led-Red/story-20520370-detail/story.html#ixzz2ruB8GnRT)

[NutLoose]

I may well have missed it despite careful perusal of all the posts, but what DID initiate the seat firing ? I have not yet seen the SI report.

I don't think it was conclusively determined, with the handle already pulled out of the holder it could have been anything from simply knocking it with his leg to putting something in a pocket, and sadly the only person who could answer that question is no longer with us, maybe the service board of enquiry will elaborate on how much movement was required to initiate ejection when the seat handle was in the raised position.

[Background Noise]

Nutloose,

Man sep does not bypass the scissor shackle.

[Wrathmonk]

Background Noise beat me to it but this MB link (http://www.martin-baker.com/products/ejection-seats/mk10) tries to explain the sequence of events (man sep covered under 'Functions' and 'high speed/high altitude').

[NutLoose]

So tell me this, do you think the Coroner and the RAF were aware that the Civil Aviation Authority issued an Emergency AD on this very problem for privately operated aircraft with Ejector Seats way back in

NOVEMBER 2011

http://www.caa.co.uk/docs/33/20111117MPD2011008ESuperseded.pdf

[Just This Once...]

Check the date.

[Background Noise]

Yes - but that was after this accident.

[NutLoose]

No the 2013 one was an amendment, the 17 of November 2011 one I linked to shows they issued an AD to check the shackle has movement.

[Background Noise]

Yes - but the accident was on 8 Nov 2011.

[Could be the last?]

As I recall, post this tragic incident, Martin Baker declared categorically that their seat was not to blame; which is obviously not the case in this incident. Notwithstanding the lives that have been saved using the various MB seats, this was a very bold statement, and having worked alongside some of their personnel, it is typical of the very arrogant stance they have taken with a number of projects!!

As has already been noted it is interesting that the MOD/RAF has already paid out, why hasn't MB been held accountable?

Just found the link, however, the connection has been removed! But it stated:

http://www.martin-baker.com/getdoc/613a0e91-0e5b-4f15-84aa-8ebff5f43a5e/Press-Releases.aspx

RAF Red Arrows Incident on 8th November 2011
On 8th November, there was a fatal accident involving the Red Arrows Hawk aircraft XX177 following the ejection of a Mk10B seat.

We have had the opportunity to examine the seat and, while not wishing to pre-empt the outcome of the investigation currently underway, are satisfied that neither a mechanical nor a design fault were to blame for the fatality.

We welcome the opportunity to assist the Lincolnshire Police and the Military Air Accident Investigation Board in identifying the causes of this tragic accident

[NutLoose]

Thanks background, sorry, I thought it was last year, thanks for clarifying the manual release also.

Could be last, denying liability is normal civilian wise as they can be held liable, a bit like when you have a car crash, you are not supposed to admit liability.

[awblain]

By the time you've paid people to argue amongst the parties involved, it might just be cheaper and easier to settle. That way the settlement money goes to those who need it rather than those doing the arguing.

In this case, the operator surely had some involvement in the events that lead to the manufacturer's item not working as designed, so it would just be a very expensive and time-consuming argument to split the inevitable costs.

In the case of a car crash, the insurer doesn't want the insured to admit fault, so that they can run that discussion themselves.

[SirPeterHardingsLovechild]

Chug
A new MOD tactic to settle before both inquest and SI publication? Now why would they do that I wonder?


I think you have that 100% arse about face. If the MoD have already admitted 100% liability, then the only direction this could have gone would have been against the family, that is, if the Coroner or SI mentions some degree of contributory negligence by Flt Lt Cunningham himself. It would be the family's lawyer who would advise them to accept.


5F6B
I agree with you entirely


Wrathmonk
Doesn't matter where the seat pin is or isn't if the scissor shackle has been over tightened.


If a member of the groundcrew had been the victim, he wouldn't have been strapped in and the scissor shackle would be irrelevant. And Flt Lt Cunningham might have been up for a Court Martial

[JFZ90]

mb have made this statement on their site

News and Events (http://www.martin-baker.com/news-and-events)

they are distancing themselves from blame here, which is a bit off, but on the other hand the use of the words "entirely useless" by the coroner were "entirely inappropriate" and designed to grab headlines.

i would be interested to know what the pubs say (and have historically said) about the shackle - it seems some on here are clearly aware that overtightening was a risk, but from the inquest the pubs seem unclear on this which seems rather surprising given the consequences.

[SirPeterHardingsLovechild]

Worth a cut & paste for the record

MB Website 30th Jan '14

RED ARROWS INCIDENT ON 8TH NOVEMBER 2011

On 8 November 2011, Flt Lt Sean Cunningham died when he inadvertently ejected from an RAF Hawk T1, the seat pan firing handle having been mistakenly left in an unsafe position.

We would like to extend our sincere condolences to Flt Lt Cunningham’s family and friends. Martin-Baker is a family owned company producing vital equipment for people doing a dangerous and important job. We take our responsibilities to these individuals very seriously and we are all deeply saddened by this terrible accident.

The ejection seat is qualified to save a life on a ground level ejection (zero-zero). On this occasion, uniquely in the entire history of Martin-Baker ejection seats using this particular feature, it failed due to a shackle bolt being too tight. This prevented the main parachute from deploying.



We supplied the seat to Hawker Siddeley (now part of BAE Systems) in 1976. Since then, for the last 35 years, the seat has been used and operated by the RAF.

In light of this incident, lessons have been learned and we have taken steps to alert all our customers worldwide who still use this type of seat, of the risk of over tightening the shackle. Furthermore, our designers, working closely with military experts have developed a new type of shackle bolt and firing handle housing, which both Martin-Baker and the military authorities consider will prevent the reoccurrence of the circumstances that led to this tragic accident.

Martin-Baker is proud to be able to say that, since 1946, it has led the world in the design development and manufacture of ejection seats. As of today's date these seats have saved 7436 lives, seven in this month alone.

[Just This Once...]

Probably worth doing the same for their first press release:



RAF RED ARROWS INCIDENT ON 8TH NOVEMBER 2011

November 2011

On 8th November, there was a fatal accident involving the Red Arrows Hawk aircraft XX177 following the ejection of a Mk10B seat.

We have had the opportunity to examine the seat and, while not wishing to pre-empt the outcome of the investigation currently underway, are satisfied that neither a mechanical nor a design fault were to blame for the fatality.

We welcome the opportunity to assist the Lincolnshire Police and the Military Air Accident Investigation Board in identifying the causes of this tragic accident

In the meantime, our thoughts and prayers are with the family and friends of Flight Lieutenant Sean Cunningham who lost his life in this accident.

[SirPeterHardingsLovechild]

On another matter, I am absolutely mystified about how the jump was made to state that the seat pan safety pin had been fitted incorrectly after the penultimate flight on Friday 4th November.


I have a better explanation but I will have to wait for the SI report

[Chugalug2]

SPHLC:-
I think you have that 100% arse about face.
So they settled out of consideration for the family? That would be a first! The MOD is less concerned about liability (after all the pay-out is our money, not theirs). Their worry is that evidence should not emerge of any MOD negligence or incompetence. That is less likely to happen if the sequence is as in this case; settle, allow late sight of SI report to family only, ensure that their version of events is about all that is available to the Coroner, finally release SI report after Inquest. MBA taking the hit makes for a satisfactory outcome all round.

[The Oberon]

Slight thread drift but what happens to an airframe following zero/zero ejection, are they recoverable ?

[SirPeterHardingsLovechild]

Chug:-

So they settled out of consideration for the family?

No - The MoD made an offer, the family settled.

Please be aware that it was your campaign (and tuc, Nige Gilb, Flip etc) that gave me the courage to sue the MoD and win, spectacularly.

Most civil suits are No Win No Fee, or Conditional Fee Agreement (CFA). In the latter CFA you are insured against costs on the grounds that when your lawyer says "That's as good an offer as we can expect" you have to accept, or be liable for costs of both sides.

[Chugalug2]

SPHLC, I take your point re accepting the offer when advised to do so by your lawyer. It is the timing of the offer before Inquest and SI publication that is new AFAIK. I find that significant.
On behalf of the tightly knit group of politically motivated old men, thank you for your kind words. I'm glad that we encouraged you to take on the MOD. Would that others would too re military airworthiness reform.

[longer ron]

Slight thread drift but what happens to an airframe following zero/zero ejection, are they recoverable ?

In this particular and highly unusual case - yes the airframe suffered no significant damage and therefore could be made airworthy by carrying out a 'penalty' servicing,replacing the damaged components and replacing the engine !

rgds LR

[SirPeterHardingsLovechild]

Chug.


If the MoD offered early and large, then we are both right, and it is significant.

[lj101]

Chug

The family were aware of the results of the SI many months ago - I've probably misinterpreted what you have said.

[dragartist]

I am eagerly awaiting the debate over the effectiveness of the "Just Culture". no doubt the SI will be redacted to protect those named. Sorry but it has to go back to those in 76 who put ink to drafting film, those formations named in the post above from ARSE who evaluated the design and made the CA Release recommendations. (A squared E squared, IAM etc) the person who signed of the first CA release and every one who declared themselves to be a Subject Matter Expert and SQEP who reviewed publications and the safety Case (read Hazard log) and declared each entry ALARP. Will the Cassandra file be an annex to the SI?


listened to an Ex RAF guy on the local BBC radio this evening at around 19.10 by name of Brookes. I just could not believe how he was defending the RAF stating how open they are in comparison with the NHS when things go wrong. Not in my experience I am afraid.

[Photoplanet]

Quoting Longer Ron:

In this particular and highly unusual case - yes the airframe suffered no significant damage and therefore could be made airworthy by carrying out a 'penalty' servicing,replacing the damaged components and replacing the engine !
Why was the engine identified for replacement in this case, was it resultant from the ejection ?

[Genstabler]

Ingested bits of canopy presumably.

[Photoplanet]

Well, that was my thinking... And if the engine was running, the pins would have already been removed, at least that was the case when I was Tornado F3 Groundcrew...

I am currently on a course with someone from the 'Flight Safety Investigation' branch of the RAF, and have been privy to some info that should be in the Service Inquiry, so I will not detail it here, in case it is not suitable for 'public release'.

Suffice to say (as always) there are lessons that can be learnt.

[NutLoose]

Yes, plus the rocket gasses and associated junk from that, didn't one if the groundcrew say he shut it down? I seem to remember reading that on the tweets.

[stickstirrer]

I concur with RetiredBA/BY ( I have 19 years experience flying the T1). The initiation of the seat firing still seems to me to be the most peculiar thing about the accident. The pull needs to be substantial and it seemed very odd that the handle could have been inadvertently operated sufficiently to then make its subsequent accidental operation rather easy. Pins have been wrongly inserted before leaving the seat unsafe, but the initiation still seemed improbable and very peculiar. There was an incident many years ago of a Harrier pilot stepping onto a seat handle which was unsafe and being ejected but that took his weight to apply considerable leverage to bend the handle over a fulcrum point and initiate the sequence. I hope that Sean's sad death will at least lead to a redesign of the handle stowage to minimize any possible repeat of these circumstances. (Anyone remember the Gnat safety handle that dug into the back of your neck if you didn't move it through 90 degs to make the seat live? and the inflight pic of a Red Arrow leaning forward in his seat with the handle still forward in the 'safe' position?)

[GreenKnight121]

Slight thread drift but what happens to an airframe following zero/zero ejection, are they recoverable ?In this particular and highly unusual case - yes the airframe suffered no significant damage and therefore could be made airworthy by carrying out a 'penalty' servicing,replacing the damaged components and replacing the engine !

And in this (http://fly.historicwings.com/2013/02/the-cornfield-bomber/) case, the single-seat aircraft was repaired and returned to service after an INFLIGHT ejection! ;)

[tucumseh]

dragartist

I am eagerly awaiting the debate over the effectiveness of the "Just Culture". no doubt the SI will be redacted to protect those named. Sorry but it has to go back to those in 76 who put ink to drafting film, those formations named in the post above from ARSE who evaluated the design and made the CA Release recommendations. (A squared E squared, IAM etc) the person who signed of the first CA release and every one who declared themselves to be a Subject Matter Expert and SQEP who reviewed publications and the safety Case (read Hazard log) and declared each entry ALARP. Will the Cassandra file be an annex to the SI?


Excellent. And unfortunately we've been there before too often.

MoD always look to the final act, but these defences in depth have been systematically weakened over many years. Yet they are money in the bank to both the designer and MoD.

To your list I'd add the Design Reviews (especially the Critical Design Review) and Installation Design Conference (the 555), when as many knowledgeable people you can spare from the squadrons are allowed to crawl all over every aspect of the design and installation.

In the 1990s building these defences became optional, and in the case of CDRs non-technical staff are now permitted to waive them, yet sign a declaration to the effect they have been held, successfully. That, of course, is a serious fraud; DE&S has expressed itself content, and Min(AF) and the Head of the Civil Service have accepted this advice and upheld the policy.

Given the MAA is part of this cowboy outfit, it is little wonder we're repeating ourselves yet again.

[Finnpog]

GK121 - an excellent story on that link, and nearly an anniversary as well. Thanks.

[Distant Voice]

So they settled out of consideration for the family? That would be a first! The MOD is less concerned about liability (after all the pay-out is our money, not theirs). Their worry is that evidence should not emerge of any MOD negligence or incompetence. That is less likely to happen if the sequence is as in this case; settle, allow late sight of SI report to family only, ensure that their version of events is about all that is available to the Coroner, finally release SI report after Inquest

Spot on. And the same approach will be adopted for the Tornado FAI; if it takes place.

DV

[lj101]

The families from the Tornado FAI have already had sight of the SI (a while ago).

I don't know if there has been a settlement though.

[Zulu 10]

dragartist




Excellent. And unfortunately we've been there before too often.

MoD always look to the final act, but these defences in depth have been systematically weakened over many years. Yet they are money in the bank to both the designer and MoD.

To your list I'd add the Design Reviews (especially the Critical Design Review) and Installation Design Conference (the 555), when as many knowledgeable people you can spare from the squadrons are allowed to crawl all over every aspect of the design and installation.

In the 1990s building these defences became optional, and in the case of CDRs non-technical staff are now permitted to waive them, yet sign a declaration to the effect they have been held, successfully. That, of course, is a serious fraud; DE&S has expressed itself content, and Min(AF) and the Head of the Civil Service have accepted this advice and upheld the policy.

Given the MAA is part of this cowboy outfit, it is little wonder we're repeating ourselves yet again.

As a long time lurker and very infrequent poster I have to say that I am saddened by some of the frankly myopic and self-serving sentiments that are being expressed here. As a designer though I’m furious:

The death of Flt Lt Cunningham was tragic, as is every other needless death that occurs as a consequence of an aircraft accident.

Those on here who know who I am, and remember my contribution to TELIC 1 may also remember the post TELIC 1 conference at Marham.

At the opening of that the staish gave a briefing which paraphrased said: “give me the tools…” (he meant the upgrades to the jet) “… and an appraisal of the safety… or not.. and let me determine the benefit vs risk …and choose to take or not take it into battle accordingly”

Now, for a variety of reasons which we all know, that brave but slightly cavalier (sorry Sir) attitude simply is neither feasible nor is it favourable in today’s world.

At the other end of the scale we have this emotive sentiment being rattled out which would apparently seek to find anyone involved in the design chain, at whatever level, and hang them out to dry if any tiny thing should go wrong . Ever!

Now if that’s the way you want to play the game then fine, so be it.

But just remember this: if you ‘phone me and ask me to drop everything in order to design, build, integrate and clear a UOR onto a fast jet in a matter of literally weeks, then guess what? I’ll tell you to get lost, I’m busy. I really don’t need the stress today, and I certainly don’t want it in ten years time when some-know-it-all uses the benefit of 20-20 hindsight to point out something that I missed, and that didn’t get spotted at PDR, CDR, TRR or any other R!

If flexibility really is the key to air power, then you have to understand that it works both ways. ‘He who never made a mistake never made anything’ as the saying goes, the corollary of which is that if you want something made, then as a consequence it must be accepted that sometimes mistakes will occur.

No one, me included, has not been shocked by what Haddon Cave has uncovered, and yes, there are areas where accountability is lacking. But please don’t tar everyone with the same brush.

After the H-C report was published I had conscientious hard-working young engineers come to me to ask whether they could end up in jail for making an honest mistake in the design process. The gist of what I told them was “no, you’ll not end up in jail if you…try hard… be honest…tell everyone the truth….and document everything…and you’ll be ok”.

Sadly, it sounds as though if some of you lot had their way that wouldn’t be the case.

Is that really what you want?

[tucumseh]

Zulu 10

Thanks for that. I fully agree that the people I describe, who caused so many deaths, are "myopic and self-serving".

No one, me included, has not been shocked by what Haddon Cave has uncovered

I wasn't shocked. He didn't uncover any failure that wasn't already in the public domain; and certainly known by anyone in MoD with any knowledge of airworthiness. How many of these people met their legal and moral obligation to report, and escalate, these failings? What he did do was protect the myopic and self-serving, by naming and blaming the wrong people. We also agree that this should never be the case.

[dragartist]

Zulu,
I came up though the design route to become the EA for some serious kit. I received commendations for my work on Granby and Jacana. The citations majored on my attention to detail and not compromising safety. I turned some jobs round very quickly to give the front line the tools you describe.


I recognised it was time to leave when my moans about the compromises being made were being shunned.


Let me give you just one example that may have some relevance to this thread. it would have been 2000 or 2001. A safety manager (C1 Grade CS) post was established in the team I can't recall the blokes name, he was insignificant. he was soon diverted to Business Management tasks. The IPTL at the time had is priorities wrong in my mind. I don't think I am alone in my view.


As Tuc has stated several times on several threads there has been a gradual watering down of the resources supporting efforts over the years.


Only following C H-C was money being thrown at Safety. Too little too late and too poorly focused. What I saw was it being contracted out to the likes of Q2, ERA etc. The in house expertise had gone never to be recovered.


I once worked for the military advisor to C H-C he taught me a fair bit. the most significant thing was to fully understand the kit I was responsible for.


Standing by to repel boarders.

[Zulu 10]

Zulu,
I came up though the design route to become the EA for some serious kit. I received commendations for my work on Granby and Jacana. The citations majored on my attention to detail and not compromising safety. I turned some jobs round very quickly to give the front line the tools you describe.

I recognised it was time to leave when my moans about the compromises being made were being shunned.

Let me give you just one example that may have some relevance to this thread. it would have been 2000 or 2001. A safety manager (C1 Grade CS) post was established in the team I can't recall the blokes name, he was insignificant. he was soon diverted to Business Management tasks. The IPTL at the time had is priorities wrong in my mind. I don't think I am alone in my view.

As Tuc has stated several times on several threads there has been a gradual watering down of the resources supporting efforts over the years.

Only following C H-C was money being thrown at Safety. Too little too late and too poorly focused. What I saw was it being contracted out to the likes of Q2, ERA etc. The in house expertise had gone never to be recovered.

I once worked for the military advisor to C H-C he taught me a fair bit. the most significant thing was to fully understand the kit I was responsible for.

Standing by to repel boarders.

All very commendable (pardon the pun) and I suspect our paths may have crossed in a previous life, but none of that IMHO excuses your previous comment about the inquiry in the case of this accident which in your words " it has to go back to those in 76 who put ink to drafting film" and which was echoed by Tecumseh's slight about "designers".

The original designer may, and I emphasise "may" have failed to notice a flaw in his/her work, but that doesn't mean that they should be pilloried if subsequent reviews etc didn't spot it either.

If, as I think you are suggesting, the reviews are not carried out thoroughly and dilligently, and the recommendations followed, then we're in full agreement that heads should roll.

Where we seem to differ is in our view of whether the designer is responsible if the review/clearance 'system' fails in its duty.

[dragartist]

Zulu, you are absolutely correct it is a team effort. I share the blame with the evaluators who are the designers safety net. Perhaps even the maintainers who could perhaps have raised a number of 760s and 765s. (Maybe they did and the Station or EA did not act on them) One point I tried to make was the erosion of all the formations who supported continued airworthiness. The Publications at Glasgow closed, CSDE closed. IPT assumed responsibilities but had their manning cut. My example of the Safety Manager is true. My team halved in two years, my PDS budget continuously salami sliced. my DERA then Q2 budget cut significantly. Just been reading the Aero Society mag on DE&S+ and listened to Hammond yesterday at Yeovil. The penny is starting to drop but it has taken Chinook computers, Herc ESF, Nimrod fuel and hot air ducts and bang seats. What's next.


Just saying it as I saw it.

[Chugalug2]

Good post, Dragartist. The system can only work as a team, united in its earnest desire to ensure airworthy aircraft. We have to get back to such a system. There is a long way to go. About time we started out then.

[dragartist]

I meant to add that my comments were intended to be generic not directed specifically to the topic of this thread. I am sure my ex colleagues on the IPT are under enough pressure.


I figure we are all eagerly awaiting the publication of the SI. It was not on the MAA web site earlier this evening when I checked. I did note that some of the ASIMS forms I had a early hand in had developed nicely. Well done Mike.

[tucumseh]

Zulu

Please explain.

which was echoed by Tecumseh's slight about "designers".I talked of Design Reviews, and the policy decision by CDP and his staff (especially DGAS2/XD1 - Nimrod, Chinook) that they may be waived by non-technical staff, and a false declaration made that they were held successfully, and full payment made. Like dragartist, I state a simple fact, and DE&S has on many occasions confirmed this practice is acceptable, most recently last month. I am quite comfortable repeating this. It was submitted in evidence to both Haddon-Cave and Lord Philip; and less than a week ago to the HofC Defence Committee. At no time has MoD sought to refute what I say.

In fact, DE&S has been extremely helpful in this matter, offering to provide the correspondence from CDP upholding these rulings. Think about that. DE&S has staff so utterly and completely barking, or supremely confident of the top cover from VSOs (probably both) that they offer to provide the written evidence that it is stated policy to discipline staffs who seek to implement mandated airworthiness regulations, and support to the hilt staffs who commit fraud.

And the MAA is FULLY aware of this, having been informed in the presence of a Minister and been party to the above DE&S correspondence. The record of proceedings is very clear! Neither took any action. That gets to the root of the problem. Those few staffs who met their legal obligation were castigated and disciplined for their impertinence, and despite the Nimrod Review and the changes it has brought about in MoD, they are still castigated, despite being proven 100% right. The official Ministerial line remains that there have been no systemic airworthiness failings. So why was the MAA formed?

Finally, how daft does it look sniping at someone who has consistently fought for aviation safety, yet in the same breath list a raft of things both you and I fully agree upon. It makes me think what is upsetting you/MoD is WHO revealed the failures and, more to the point, WHO ordered and perpetuated them while aircrew were dying in avoidable accidents. Please don't shoot the messenger.

[oldmansquipper]

DA

You said : "Perhaps even the maintainers who could perhaps have raised a number of 760s and 765s".

Perhaps they could/did - However....

In the Mid 80 - to early 90s, I recall the mantra that came out of (some) Eng Wg HQs I knew and loved was "Do you realise how much it costs to raise a F760?" ...this was often followed by a ripping sound emanating from handbrake house.

Later, and whilst in an EA post processing (amongst many other things) loads of 760s & 765s, We developed a very good working relationship with `Mr 765`(A Sqn Ldr M**dl*** IIRC) and all was well until the 765 cell disappeared in a puff of smoke amongst the headlong rush to MDGs or IPTs or whatever the latest yukspeak term was. A great shame, as the work load then fell onto a rapidly restructured IPT which had been reduced in size, reorganised (several times) relocated (several times) and largely civilianised... CSDE disappeared around this time as well...And if that wasn't enough, all this was happening in and around Gulf War 1.

Without a doubt, things got missed. It was (and is, I guess) a sad state of affairs.

[Easy Street]

I'm no expert on the airworthiness saga, but I think I've picked up enough from tuc and Chug over the years to understand that the problems date from the late 80s / early 90s - correct? Therefore, since the Hawk entered service in the 1970s, I presume that a fully-functioning airworthiness organisation scrutinised the design of the ejection seat and found no problems with either the firing handle safety pin or the scissor shackle.

If MB's information regarding overtightening of the scissor shackle bolt was released in the 1990s then it conceivably might have got lost in the by-now-dysfunctional airworthiness organisation, in which case the MoD could rightly be blamed. However MB have not challenged the accusation that they failed to inform the MoD about the issue. To me it seems a bit churlish, in the absence of any evidence whatsoever, to assume that the MoD must have received and failed to act upon the information.

As for the seat handle and safety pin, if its design was approved by the fully-functioning airworthiness organisation of the 1970s, and there were no instances of handles being pulled to a hair trigger position until Sean's accident, then how exactly was anyone supposed to recognise and mitigate the risk? I think we know that a few pilots have inadvertantly pulled the handle a little way and then pushed it back in on various marks of seat; if these instances were never formally reported or acted upon then the failure was not so much in airworthiness funding as it was in aircrew reporting culture. And I think we all know how poor that was in the 1970s / 1980s!How, exactly, would airworthiness process have identified the hazard without an incident report?

It seems to me that the best opportunities to stop the accident were the visual checks of the seat safety pin. As I said in an earlier post, having seen mock-up photos, the clues were subtle but they were definitely there. Of the 19 opportunities to spot the condition, at least 4 would have belonged to Sean as he pinned the seat, got out, got back in, and unpinned the seat. Knowing a little of the Reds' way of doing business, the fact that the SI president testified about their unit culture at the inquest suggests to me that the report (which I have yet to see) will touch on self-imposed time pressures, which (if true) would further reduce the likelihood of spotting the condition of the seat handle.

This is not Nimrod or Patriot; there were opportunities for the Reds' management, the lineys and the pilot to identify weaknesses or faults and break the accident chain. There may well have been design and communication failings elsewhere but I do not believe that this accident was fundamentally the making of a dysfunctional or negligent airworthiness organisation. The payout is at least as likely to result from acknowledged failings within Air Command as it is within DE&S, in my view...

[NutLoose]

This is not Nimrod or Patriot; there were opportunities for the Reds' management, the lineys and the pilot to identify weaknesses or faults and break the accident chain.

It totally goes back to what you expect to see, the photos clearly shows the handle out of it's housing, but looking down on the seat you will be seeing it from a different perspective and to be honest your mind set would be concentrating at looking at the pin being in, especially as you would be unaware that there was a design fault and it would as far as you knew be impossible to fit the pin without everything being correct, hence your attention of focus would be the pin.

The CAA at airshows actually present a light aircraft with built in faults present, split pins in controls missing, screwdrivers in engine compartment, nuts missing off wheels etc then invite members of the public / engineers / private pilots/ commercial pilots etc to spot the faults...... Very very few actually find them all, indeed the majority do not even come close, and they know there are faults present.

[Zulu 10]

Zulu

Please explain.

I talked of Design Reviews, and the policy decision by CDP and his staff (especially DGAS2/XD1 - Nimrod, Chinook) that they may be waived by non-technical staff, and a false declaration made that they were held successfully, and full payment made. Like dragartist, I state a simple fact, and DE&S has on many occasions confirmed this practice is acceptable, most recently last month. I am quite comfortable repeating this.....

.... Finally, how daft does it look sniping at someone who has consistently fought for aviation safety, yet in the same breath list a raft of things both you and I fully agree upon. It makes me think what is upsetting you/MoD is WHO revealed the failures and, more to the point, WHO ordered and perpetuated them while aircrew were dying in avoidable accidents. Please don't shoot the messenger.

Yes, we do agree on the the erosion and consequent failures of the review, clearance, and release system. Also on the need for dishonesty to be penalised.

What I do not agree with is your point in #299 that "MoD always look to the final act, but these defences in depth have been systematically weakened over many years. Yet they are money in the bank to both the designer and MoD."

Your post was supporting Drag Artist's post in which he had suggested taking responsibility for this dreadful accident all the way back to the application of ink to drafting film. i.e. to the designer.

My concern being your statement, also castigating the "designer". It is the position of the designer that I am attempting, but apparently failing, to defend. I am proud to say that I have never met a designer who would place money above safety.

Corporations and design organisations might, but designers? Never.

I'll agree not to shoot the messenger if you agree not to shoot the designer.

[tucumseh]

"Do you realise how much it costs to raise a F760?"Precisely. This very point, and supporting evidence, was submitted to both H-C and Lord Philip.

Briefly, this was a "saving at the expense of safety" (see Nimrod Review) thought necessary because in 1991 AMSO (the RAF Chief Engineer) had failed to correct the wasteful policy issued by his predecessors in June 1987 (formulation) and January 1988 (promulgation without discussion or warning).

All he had to do was rescind the policy, and was advised to do so by successive internal audits (e.g. EAC), but refused. Why? MoD won't say but the refusal protected his predecessors. The money had to be found from somewhere so he simply applied successive 28% cuts to direct airworthiness tasks, year on year. (Remember, Haddon-Cave criticised General Cowan for 4% cuts imposed upon him from above, but praised the instigator of 28% cuts). Don't take my word; it is noted in the August 1992 CHART report by Inspector of Flight Safety. That was withheld until obtained during the Mull of Kinttyre reveiw.

MF765s were stopped (which would be a confusing message to industry - MoD don't want tech pubs to be correct). EAs were under orders to save up MF760s, regardless of safety implications. Even if an EA broke the rules and submitted a 760A, funding had been entirely withdrawn for the investigation. This ethos extended across all 17 components of maintaining the build standard (of which MF65s is a small part of one). That maintained build standard is a pre-requisite to a valid Safety Case, and hence Release to Service.

[dctyke]

Zulu 10: If flexibility really is the key to air power, then you have to understand that it works both ways. ‘He who never made a mistake never made anything’ as the saying goes, the corollary of which is that if you want something made, then as a consequence it must be accepted that sometimes mistakes will occur.

Is it a 'mistake' to not use a shouldered bolt (fitted up to and including Mk9 and Mk 12 seats) that cannot be over tightened and use one that can. If a mod does indeed come out that has a shouldered bolt I would be asking why not in the 1st place.

[tucumseh]

Zulu

Thank you.

I have never criticised designers and, indeed, have supported them consistently in my many posts. If I caused confusion, I apologise. No designer is perfect. Everyone makes mistakes. God knows I made a few howlers when I was one. But that is why the defences in depth (design reviews/configuration milestones) are mandated and I disagree with MoD's stated policy that they can be waived, at the whim of a non-engineer. It is a slightly different issue that he is also allowed to make a false declaration that they were held successfully, but I disagree with that as well. As always, I fully accept that many disagree with me, including the MAA and DE&S policy branch, but I'm glad you don't.


Edited to add; Sorry, I did openly criticise one company, who always put negative tolerances on their wiring/loom drawings; but as they had been awarded the major contract on a political direction, without bidding, I guess anyone would make the same criticism. Such a mistake, and refusal to correct, indicates zero subject knowledge. Perhaps worse, a non-engineer in MoD was allowed to arbitrate - he did not choose wisely. I suppose strictly speaking the original error wasn't made by a designer - loom drawings are apprentice jobs. But the designer made the mistake by signing them off.

[Zulu 10]

Zulu

Thank you.

I have never criticised designers and, indeed, have supported them consistently in my many posts. If I caused confusion, I apologise. No designer is perfect. Everyone makes mistakes. God knows I made a few howlers when I was one. But that is why the defences in depth (design reviews/configuration milestones) are mandated and I disagree with MoD's stated policy that they can be waived, at the whim of a non-engineer. It is a slightly different issue that he is also allowed to make a false declaration that they were held successfully, but I disagree with that as well. As always, I fully accept that many disagree with me, including the MAA and DE&S policy branch, but I'm glad you don't.

Thank you too. Your summary is spot on. Perhaps in future it might be preferable to use a term such as "design organisations" or "corporations" to differentiate between them and the poor s*d at the drawing board?

The business of "review held successfully" is a murky one: a review can be held during which a number of issues arise, items are minuted and actions/problems raised. Been there, done that.

Technically though, in accordance with the letter of the wording, the milestone of 'holding the review' has been met and typically a milestone staged payment is duly claimed by the supplier/design organisation.

Sadly, the fact that there are multiple outstanding issues doesn't stand in the way, and unless there's a robust way to capture those outstanding issues and ensure resolution, then the rot sets in from that point onwards.

On a number of occasions, whilst drawing up fairly large yet detailed project plans/estimates, I have been told to alter my wording from "Design Review Carried Out Successfully" or "Design Review Completed", to "Design Review Carried Out".

The nuance is, from a commercial viewpoint, quite clear....

[tucumseh]

Esay Street

I think your excellent points are best answered or explained by the mandated regulation calling for continuous assessment (of safety). Also, the associated positive feedback loop, which eliminates the need to assume (in this case, receipt, or otherwise, of servicing bulletins).

How can we have continuous assessment if (a) funding is cut by 28% per year to conceal waste and, (b) posts are chopped as the cuts mean the staff cannot do their work and are sitting idle? (In January 1993, when we were told there would be no funding to maintain safety, we were advised to ship out and seek jobs elsewhere. 38 of us left, in my case returning to MoD(PE); only one stayed. That's a lot of experience to lose in one year, and have no means of replacing it. Not that the Chief Engineer wanted to).

Both Haddon-Cave and Lord Philip, plus every ART report I've read, mentions the failure to implement this policy in one way or another.

[tucumseh]

Zulu

I must admit I didn't think of myself as a "poor sod", I rather enjoyed the job! I had good teachers.


I agree with the issue of nuances. But when signing off the work (a delegation granted only to engineers, my complaint being non-engineers are now allowed to self-delegate) you are signing to say the work has been carried out in accordance with the contracted specification. The MoD engineer is, uniquely, allowed (required) to exercise engineering judgement and defer issues, but only in exceptional circumstances. A typical example would be interface parameters not yet established from a parallel development. But, the good book says;

A Critical Design Review (CDR) is defined as a review to determine if the detailed system design meets the performance and engineering requirements (including safety) of development specifications. During CDR, the MoD must ensure that all design areas are adequately examined, that design weaknesses are identified, and that solutions for design-related problems are available. The MoD must use the results of the CDR to assess the readiness of the system to progress to the next acquisition phase. The design reviews and associated testing of design features let the MoD review the complete system design and evaluate its capability to satisfy total mission requirements, safely. The CDR should be effective and not rely on later production efforts to resolve design deficiencies.




Ever so slightly ambiguous, but it needs to be to allow deferments. But what it doesn't allow is a false declaration that the design is safe, knowing it is not!

[Zulu 10]

Zulu 10: If flexibility really is the key to air power, then you have to understand that it works both ways. ‘He who never made a mistake never made anything’ as the saying goes, the corollary of which is that if you want something made, then as a consequence it must be accepted that sometimes mistakes will occur.

Is it a 'mistake' to not use a shouldered bolt (fitted up to and including Mk9 and Mk 12 seats) that cannot be over tightened and use one that can. If a mod does indeed come out that has a shouldered bolt I would be asking why not in the 1st place.

I’m struggling to understand what you’re asking. Are you suggesting that the design which did not utilise a suitable shoulder bolt was a consequence of:

1. Pure (innocent) incompetence on the part of the designer, coupled with a lack of oversight by more experienced staff, or;

2. A review which noticed the potential for failure, but quietly and cognisantly ignored that matter, or;

3. A desire to save a few pennies in production by using cheaper part, or;

4. A belief by the equipment designer that an appropriate torque figure would be quoted in the accompanying servicing Tech Order, and a suitable torque wrench would be supplied to those requiring to adjust said fastener?

I do not know and cannot second guess it. Neither, I respectfully suggest, can you.

Are they all mistakes? Possibly. Are they all "honest mistakes"? No.

But to use the defence in depth principle, a good review process should have captured the first three and would have noticed the potential for number 4 to result in problems (i.e. Tech Pubs ignored, torque wrench out of cal etc) and therefore added a second defence mechanism i.e. a shoulder bolt.

You also seem to be suggesting that every design should be right first time. You’re a creationist I assume?

[Zulu 10]

Zulu

I must admit I didn't think of myself as a "poor sod", I rather enjoyed the job! I had good teachers.


I agree with the issue of nuances. But when signing off the work (a delegation granted only to engineers, my complaint being non-engineers are now allowed to self-delegate) you are signing to say the work has been carried out in accordance with the contracted specification. The MoD engineer is, uniquely, allowed (required) to exercise engineering judgement and defer issues, but only in exceptional circumstances. A typical example would be interface parameters not yet established from a parallel development. But, the good book says;

A Critical Design Review (CDR) is defined as a review to determine if the detailed system design meets the performance and engineering requirements (including safety) of development specifications. During CDR, the MoD must ensure that all design areas are adequately examined, that design weaknesses are identified, and that solutions for design-related problems are available. The MoD must use the results of the CDR to assess the readiness of the system to progress to the next acquisition phase. The design reviews and associated testing of design features let the MoD review the complete system design and evaluate its capability to satisfy total mission requirements, safely. The CDR should be effective and not rely on later production efforts to resolve design deficiencies.




Ever so slightly ambiguous, but it needs to be to allow deferments. But what it doesn't allow is a false declaration that the design is safe, knowing it is not!

Now you've opened another can of worms:
In my experience of dealing with MOD: the "contractual specifications" including the technical content, and the "the performance and engineering requirements (including safety) of development specifications" are often completely different documents.

One sometimes a mere sub-set of the other, thereby allowing (encouraging?) a desk officer (and as you say, sometimes a non-engineer) to sign off a milestone as being complete in accordance with teh contracted spec, whilst still not meeting the development spec.

I think you and I agree that those gaps should be closed, but financial pragmatism dictates otherwise. I'm not defending that, just saying how I see it.

Now I really must get on with some proper (paid) work.

[Chugalug2]

Zulu 10, it seems to me that we are all singing from the same hymn sheet, but perhaps from different verses. What you say as a designer is that you assume/depend upon a process of continuous review to ensure that your design was and remains in accordance with the airworthiness regulations. When you designed it you did so within the same regulatory constraints.


That in a nutshell is the system that worked for years, until the late 1980's, when VSO's set out to subvert it in order to balance their books. It has never recovered to this day. That is what has now to be attended to. It is not being resolved by the MAA or MAAIB, nor can it be until they are independent of the MOD and each other. That is the gist of this discussion.


Easy Street, there never was a "Golden Period". That cynical phrase comes from the H-C Report, itself a cynical misrepresentation of history. Any Aviation professional knows that "stuff happens", always did, always will. The point is, what do you do about it? What we did in the 60's was the RAF Flight Safety System and a beefing up of Airworthiness Provision. Avoidable accidents, so rife in the 50's, began to fall but never to zero of course. You do the best you can, and ensure a continuous feedback loop to try to do better. When that system was kicked in the teeth under the auspices of the RAF Chief Engineer, the whole process of continuous audit stopped working, and "stuff" started happening again with a vengeance!

[foldingwings]

Ah - there you go again, BEagle! Never miss an opportunity to swipe at the Buccaneer. The Staff Nav was probably so pi:mad::mad:ed off with you that he was working out just how to write up another of your failed sorties! Was it that sortie that led to you being chopped?

No excuse for messing up his pins but, since he knew he was flying with a smart ass, he was probably quite confident that you would sort it out for him!

Back in the Fold:ugh:

PS. That always assumes that your story is true, of course, and not just more anti-237 OCU BfB (Bo:mad::mad:ocks from BEagle)


BEagle:

I think that the aircraft I flew which had the most pins was the Buccaneer - clearly it was essential to ensure that they were all in the correct position pre-start and also before exiting the aircraft.

On one occasion, I don't know why, but after I'd checked my cockpit, something made me go back and check the rear seat after the navigator had climbed out. Wherupon I found that he'd transposed 2 pins into the wrong locations, meaning that one element of the seat wasn't safe as one pin was longer than the other and wasn't doing its job, being in the wrong hole.

So I relocated them into their correct locations, then joined my navigator in the line hut. True to form, being a 237 OCU staff navigator, the first thing he said was "Where the f*** have you been?". When I told him, he said "Rubbish - and how dare you stick your nose in my cockpit"......

Typical of the sort of treatment we students had to put up with in those days.....

[Hockham Admiral]

I must take you to task, Beagle, because I too went through 237 OCU back in the very early 70's. (And sorry to go so off-topic).

The staff were hard on you but I always found their criticism to be realistic and fair. If you weren't up to scratch you were given a roasting. A certain BWI could (and did) bring tears to grown men's eyes!

I always thought that this was perfectly fair as the Buccaneer maritime role was bloody well dangerous and they had to make certain you were up to scratch before you continued with the next part of the course.

I remember Night MDSL (Dive Bombing) at Theddlethorpe Range was particularly challenging and had only total admiration for the Staff Navs who sat in the back without an artificial horizon and only a minuscule altimeter to call out the dive heights and release point.

[cuefaye]

"On one occasion, I don't know why, but after I'd checked my cockpit, something made me go back and check the rear seat after the navigator had climbed out."


Sure, the nav cocked up.


But what the devil made you do that?! Very, very strange ---

[Chugalug2]

cuefaye:-
But what the devil made you do that?! Very, very strange ---Let's just be very thankful that he did. Perhaps it saved somebody's life. If someone had done the same thing for Flight Lieutenant Cunningham, the OP wouldn't have started this thread. I find your remarks
Very, very strange ---

[cuefaye]

PM, Chugalug

[Fg Off Bloggs]

Fair point, Chug, but cuefaye makes a good point also!

Why would you?

The Buccaneer was very much a crew aircraft and, to make it work, there was a great deal of trust placed both front to back and back to front. There had to be; without that trust the Buccaneer Force would never have been as effective as it was and the role was very, very demanding - particularly, as the Hockham Admiral says, in the maritime role. Backseaters were as much responsible for the safety of the aircraft as the frontseaters and it was never more so than when doing Divisional Dive Bombing or firing a simulated pod full of rockets against a manoeuvring FPB in the dark under you own LEPUS Flare recently delivered in a toss manoeuvre before converting from the recovery into a ten degree dive! Trust in each other in the cockpit and between crews in other proximate aircraft made the Bucc tactics work!

Gone off piste, I know and sorry, but if you didn't show that trust in the cockpit or on the OCU course (either before, during or after a sortie) then you would not have been deemed suitable to pass the course.

'Nuff said!

Bloggs:cool:

[SirPeterHardingsLovechild]

Evidence given to the inquest that requires discussion

“In September 2003 I was an instructor at RAF Valley flying a Hawk. It was a night flight sortie. I was in the rear seat, the student was in the front,”
“I did the sortie, landed and taxied along. And I could not put the seat pin back in the hole. I expected it to go back into the hole in the housing and the seat pin* handle. [*pan]
“It would not go through. I could see that the handle was partly caught by a strap. The handle was not completely free from the strap that surrounded it.
“I believe pressure on the strap may have pulled the handle up. If the handle is not correctly sited, the pin will not go back into the hole.
“I was probably a millimetre away from movement that meant I would have ejected. And I was lucky to get away with that.”
An ejector seat has a locking pin, which is pulled before take-off in order for the seat to be made live in an emergency.
The operating handle can then be manually pulled from the safe position through to further settings to activate the seat.
“It is only position three that will set it off, I was at one-and-a-half.
“So the action I took was still the safe thing to do, in terms of pushing it down.”

Q1. Is the seat pan handle linkage levers or cables? (You can't push a simple cable)
Q2. Does pushing the handle back into the housing reset the mechanism
Q3. Did this individual report this incident

[tucumseh]

Zulu

financial pragmatism dictates otherwise

Agree. All I'd say is financial pragmatism should not extend to "savings at the expense of safety". As I said, a safe design, that has been the subject of robust configuration milestones/reviews, is money in the bank on so many levels.

We've discussed this aspect of procurement many times. For donkeys years it has been hammered into procurers and DEC that "80% is sometimes good enough". But the 20% should not include basic safety compromises or waivers. Unfortunately, Sir Robert Walmsley, when CDP, ruled that safety COULD be part of the 20% the Services could do without. Here's your kit, it works but is unsafe. Now shut up and *** off. Happy birthday Sir Robert. :E There are many who aren't around to enjoy theirs because of this ethos.

[NutLoose]

I would say as a Engineer if the handle has come up it must be taking up play in the system hence nothing has moved linkage wise, there is probably a bit of built in play because if there wasn't the slightest knock would trigger the seat when the pin was removed, hence allowing it to move so far before actuation, I also wonder if it is not something to do with putting you in the optimum position spine wise in the seat, the handle needs to be low enough to not get in the way, but high enough to ensure a straight back and not crouched position when operating the handle..
Wasn't that one reason the face blind handles were abandoned, one it gave fractional seconds of indecision between which to use and the other it bent you forward as you pulled it, where as a handle between your legs tends to make you you sit back in the seat when pulled.

[NigelOnDraft]

Wasn't that one reason the face blind handles were abandoned, one it gave fractional seconds of indecision between which to use and the other it bent you forward as you pulled it, where as a handle between your legs tends to make you you sit back in the seat when pulled. AFAIK the face screen puts you in the better posture? i.e. more naturally rather than seat pan where it needs to be practised.

Main reason for seat pan initially was negative 'g'. Then with the Mk9 or so, dispensed with the top handle.

Interestingly, the Mk4 - in the JP and Hunter - with 2 handles, uses the bottom handle as "preferred" in the JP, but the top in the Hunter.

Hunter ACM, with seat pan, emphasises head position v spinal injury. But also says seat pan quicker / better under positive 'g' or if canopy has gone.

NoD

[SirPeterHardingsLovechild]

Nutloose, I don't disagree with anything you say, but I'm expecting a definitive yes or no from a FJ pilot. This is after all, a deadly piece of kit.


But seeing as you took the trouble:-


If you were on a backseat trip and your strap caused the seat pan handle to come out of it's housing


Would you push it back, knowing without doubt that the mechanism was reset?
Would you tell anyone?

[M609]

The Swedes had a accidental ejection (in flight) on a JAS39 back in 2007. Is that the same type of Mk10 MB seat? In that case the pins where (naturally) not installed, but they did have incidents on ground on different aircraft with the ejection handle moving out of place when removing pins. Including when collecting a brand new one at the factory I believe.

The inflight one was caused by the anti G suit moving the handle. (Pilot got ejected when pulling G on break over the airfield) Any relevance to this case, or different design?

[NutLoose]

Would you push it back, knowing without doubt that the mechanism was reset?
Would you tell anyone?

If I was strapped into it, yes I would push it back in and yes I would tell someone, even before I got out, so they could ensure the right measures were taken, for both my and their safety. I still cannot see how the mechanism would be disturbed.

[RetiredBA/BY]

Quote:
Q2. Does pushing the handle back into the housing reset the mechanism
Q3. Did this individual report this incident

Unquote.





I find it strange that these questions, particularly #3 are even asked. A firing handle NOT in the correct position makes the whole aircraft U/S, potentially dangerous, until the experts, armourers and E/O have solved the problem and made and declared the seat and aircraft safe so obviously an immediate report would be essential. It's along time since the 12 years when I sat on an MB seat daily but in my day we treated ejections seats with the very greatest care and respect, and I never saw any of my crew or students do otherwise, is that not still so ?

So far as the deletion of the face blind handle, I seem to recall that the primary reason for its deletion was the possibility of being unable to reach it in high G situations, which happened on more than a few occasions, thus making the seat pan handle the primary one when two were fitted and, obviously, your only option on seats such as the Mk10. The advantage of the face blind was that it DID give a good spinal posture, particularly important with an 80 FPS gun as on the Mk4, (it was a hell of a kick, at the limit of what the human spine can tolerate, when not just acceleration but rate of rise of acceleration is so critical) ) and offered restraint and some protection (we did not have automatic clear visors in 60s and early 70s.) for the face and head.

..and still no one has said (or expressed a plausible suggestion) what the SI and coroner's enquiry has stated to be the primary cause of the seat firing ?

[SirPeterHardingsLovechild]

I asked the questions because


raytofclimb at post #186 on page 10 and the individual I quote at post #330 talk about pushing the handle back in. Neither of them mention sitting in the seat for an hour afterwards while the armourers make the seat safe.


You, me and Nutloose would be calling the armourers

[5 Forward 6 Back]

SPHLC,

Q1. Is the seat pan handle linkage levers or cables? (You can't push a simple cable)
Q2. Does pushing the handle back into the housing reset the mechanism
Q3. Did this individual report this incident

From my Hawk recollections;

A1. Yes. The handle is linkages rather than a cable, but the first tiny bit of pull is to remove the handle from the housing rather than start actuating the linkage. You can push it back in. We used to have to do it on the training seats when taking new students for seat briefs etc.

A2. Yes, effectively, as the mechanism's not been triggered. In reality, I doubt anyone would actually reset the seat themselves. Certainly in my time sitting on Mk10s and their equivalents, if you noticed an issue with the seat like this, you'd have an armourer meet you on the line to make the seat safe for maintenance before you unstrapped.

A3. Yes; I remember the HFOR or whatever it was at the time.

[SirPeterHardingsLovechild]

5 Forward 6 Back
Q1. Is the seat pan handle linkage levers or cables? (You can't push a simple cable)
Q2. Does pushing the handle back into the housing reset the mechanism
Q3. Did this individual report this incident

From my Hawk recollections;

A1. Yes. The handle is linkages rather than a cable, but the first tiny bit of pull is to remove the handle from the housing rather than start actuating the linkage. You can push it back in. We used to have to do it on the training seats when taking new students for seat briefs etc.

A2. Yes, effectively, as the mechanism's not been triggered. In reality, I doubt anyone would actually reset the seat themselves. Certainly in my time sitting on Mk10s and their equivalents, if you noticed an issue with the seat like this, you'd have an armourer meet you on the line to make the seat safe for maintenance before you unstrapped.

A3. Yes; I remember the HFOR or whatever it was at the time. Thank you for reply.


The usual suspects are limbering up for an Airworthiness debate, something that should command the respect of many PPRuNers, although they are a bit like a stuck record sometimes.


I have mentioned a couple of things that greatly perturb me, in previous posts.


One is that I don't see how they concluded that the seat was unsafe from the previous trip. Secondly, by not allocating blame to individuals, I think that MB are being treated shabbily. I was under the impression that Just Culture does attribute blame.


Waiting for the SI release, I think Airsound said next week

[longer ron]

Because of the design/layout of the Hawk cockpit - if one checks the front seat pan pin from directly overhead - if the handle is out of its detent but remains upright - it would be difficult to spot...one needs to move ones head forward and down to check properly !
The rear seat is much easier to check because it is being viewed from the front !

[SirPeterHardingsLovechild]

Deliverance
I don't think it matters how the seat was activated. The fact is that once the sequence was initiated the system did not work as it should have. It would be the same as not fitting parachutes, useless.

As for the handle being in an unsafe state on 19 occasions, that's another issue entirely IMHO.
There is good reason to treat the seat firing and the shackle as entirely separate issues, and with respect, I don't think you've grasped it.


If Flt Lt Cunningham had been in the Line Hut, (after the penultimate flight) signing in the aircraft (certifying by his signature that among other things, the seat was safe) and a Red Arrows Engineer, maybe doing the Friday night refuel and tow to the hangar - the seat fires! The shackle has no bearing on the engineers death as he was not strapped in. It is certainly something to be investigated, but it is irrelevant to the engineers death.


War story - In the early 80's, a Canberra electrician got muddled up and fired the canopy detonators in the hangar. This was the focus of the Unit Inquiry. The fact that 50% of the canopy dets didn't fire was very alarming and the subject of a separate investigation altogether.

[Mrmungus]

I don't think it matters how the seat was activated. The fact is that once the sequence was initiated the system did not work as it should have. It would be the same as not fitting parachutes, useless.
As for the handle being in an unsafe state on 19 occasions, that's another issue entirely IMHO.

I very much beg to differ.
Imagine what would have happened had the man on brakes been ejected from this A/C ?
(I am assuming that the seats would not have been made Seat Serv to save time for example)

Would it have mattered how the seat had been initiated ? I think it might.
Would ANYONE have believed that the poor sod hadn't been playing with the seat when it went off? RAFAT sky gods are infallible after all.
Would it have received more than 2 lines in the national press. :confused:

The pinched bolt is very much the secondary point. In almost any other scenario involving normal velocity it would probably have worked and NO-ONE would ever have been the wiser until holes in the cheese lined up again. It just wasn't his day.

Did most of you sleep through your seat lectures? Were you not interested enough to look at how it worked. Some of the comments on here make it seem that way.
It is a bomb that will do it's very best to kill you. Treat it with respect at all times.

I also repeat the question. Were ANY OTHER BOLTS FOUND PINCHING THE SHACKLE during the fleet checks or was this one the only example ?
If the MB web site statement is correct and this is a UNIQUE failure in use then it is hardly a bad design is it?
Now everyone is aware of the cause would not every Pilot, Instructor, Student, Armourer and Liney from here to eternity be checking very carefully for free movement and the correct number of threads? So is not the point about MB not having told the RAF about it not now redundant. They surely will add them to the distribution list from now on. I think the point about the former flight safety structure and culture in the RAF having been dismantled explains convincingly how that happened.

Oh! and trying to blame MB for a design flaw from the 70's or before! Grow up. It was a very sad accident which I am very glad I didn't see or have any involvement in. Let us really learn from it and never repeat it so he did not die in vain.

Don't assume check. :ok:
Rant mode off ......... And Relax. :)

[dervish]

Sir Peter

The usual suspects are limbering up for an Airworthiness debate, something that should command the respect of many PPRuNers, although they are a bit like a stuck record sometimes.

A strange post if I might say so. A few days ago you praised the same guys for giving you the strength to pursue a successful claim against MOD. Well done by the way. :ok: As far as I can see, they repeat facts because MoD keeps making the same mistakes. So far, all the facts we've heard about this accident scream airworthiness failings. If history tells us anything it is MoD has kept a lid on even worse.

[dragartist]

Good post Mr Mungus.
Yes I am quite surprised at the number of people who were/are dependent upon these seats just did not appear to know that much about them.


I have just reread my post that made reference to the original design. It went on to refer to the checks and balances that were in place commending the post that someone had made on another forum (AARSE) The hundreds of people in various formations who would have had an input to ensuring continued airworthiness. Some have disappeared altogether or watered down over the years. The design was just one slice of cheese.


I agree with others that there were two separate mechanisms (the seat pin and the shackle bolt) that came together leading to the tragedy. So far we [the public] don't know much about the pin. perhaps we might next week when the SI is made public. Reading between the lines it looks like MB/MoD have introduced a modification to address the deficiencies in both areas. They could have done one without the other. Could have done neither if they could have demonstrated ALARP.

[Mortmeister]

Mrmungus

Possibly the most perceptive post on this thread.

I feel you probably understand the equipment quite well, I wonder if you are another of St. Barbaras brethren?

[SirPeterHardingsLovechild]

Then my engineer scenario passed you by. I'll make it surreal for you:-


Flt Lt Cunningham is showing Konnie Huq, the Blue Peter presenter around a Red Arrow, she is in the seat for a photo op. Flt Lt Cunningham has checked the seat for safety. It goes off. The seat and Konnie land on Princess Diana's head, and Nelson Mandela, standing next to her has a heart attack


Please tell me what the relevance of the shackle is.

[awblain]

There's an uninterrupted chain of events from the last time the seat was secure and inert to it being accidentally fired and then failing to operate as expected.

I'd say that all the steps are relevant, especially if 19 other instances were recorded. The procedures are presumably designed to prevent any cases of accidental firing, and so any errors are notable.

I agree with Deliverance that the parachute failure was particularly serious, since it was unexpected. If that element of the seat had worked properly, then there probably would have been an injury not a death. While it might not have been a problem at speed, the seat is billed to protect at zero speed, and so its failure to do so is notable. In an uncontained engine failure and fire at the beginning of take off would it have required that performance?

The opportunity to mistighten the bolt does seem to be flaw in the design; however, if there was a shoulder to the bolt to ensure its position, it seems possible that it could contact the frame without the correct tension being set, and what would be the consequences of that? If a bolt needs to have play, then it seems particularly dangerous to lose sight of that over the years, as the natural tendency would be to tighten loose bolts. Fancy German bicycle components usually have a torque setting (with units) anodized next to the bolt hole (granted because it's easy to chew up the alloy); maybe a similar practice could have helped here

"Don't assume check?". The biggest problem seems to be a lack of appreciation somewhere in the chain from manufacture 30 years ago to accident in 2011 that the tension on the bolt is a crucial think to check. Are there other aspects of the design that could be sensitive to mis-setting and drifting to being less safe with time?

[SirPeterHardingsLovechild]

Deliverance


(sorry I edited previous post as you posted)


It will come down to definitions of the pedantic extreme. The Coroner was specifically investigating a death. The SI is to be published next week. If it is "Circumstances leading to...etc" then we already have the difference between the two.

[dctyke]

Zulu 10: You also seem to be suggesting that every design should be right first time. You’re a creationist I assume?

In the case of ejection seats with 60 years of development I will firmly put my hand up and say YES.
In my mind every ejection seat that makes it into production aircraft MUST be right first time. Creationist? maybe. I'm also someone who worked on and around ejection seats for many years.

[Flight_Idle]

Nuts' bolts. I was not an armourer, so can only talk in the most general terms.


Some have been talking about bolt tensions etc, so for those who may not be unfamiliar with nuts' bolts...


A mechanism like a fork end on flying control cables, which is supposed to have movement, would normally have a shoulder bolt to prevent pinching. Often with a slotted nut & split pin, which would be just pinched against the shoulder of the bolt to prevent vibration, then split pinned.


A slotted nut has the slots cut into the body of the nut, not designed to take tension, a slotted nut is used on bolts designed to take shear loads.


A castellated nut has scalloped extensions to the main body of the nut & is used on bolts designed to take tension (& often shear loads as well)


Just from general airframe experience, I would say that the torque loading of a non shoulder bolt onto a moving mechanism, would be unreliable, due to possible differences in the 'Stiffness' of a stiff nut.


When a piece of equipment needs to be free, so that one can easily move it by hand, 'Torque loading becomes irrelevant in my view.


I seem to remember pilots moving the shackle by hand before getting into the seat, but that was a long time ago now & I could be mistaken.


As to whether the seat would have operated as speed, that would depend upon the exact geometry of the mechanism.


Simple nut' bolts for sure, but some may not be familiar with them.

[Zulu 10]

Zulu 10: You also seem to be suggesting that every design should be right first time. You’re a creationist I assume?

In the case of ejection seats with 60 years of development I will firmly put my hand up and say YES.
In my mind every ejection seat that makes it into production aircraft MUST be right first time. Creationist? maybe. I'm also someone who worked on and around ejection seats for many years.

If this wasn't such a serious subject then I'd be rather amused by the ironies contained in your somewhat oxymoronic post. As it is I'll simply point out that in 1976 there hadn't been "60 years" of development.

I also think that you're confusing design standards with production standards - though I'm unsure if that's deliberate.

BTW: If you replace the '1' with a '0' at the end of the URL, then press refresh on your browser, you'll be able to quote others.

I too have experience, I just don't feel the need to state it publicly.

[NutLoose]

Just from general airframe experience, I would say that the torque loading of a non shoulder bolt onto a moving mechanism, would be unreliable, due to possible differences in the 'Stiffness' of a stiff nut.

Torque loading a stiff nut should take into account the stiff nut rundown torque when calculating the actual torque setting required, ie it should be preordained torque plus rundown torque to give you the actual torque loading that needs to be applied.

[dervish]

In my mind every ejection seat that makes it into production aircraft MUST be right first time.


Spot on. Pedantic to argue terminology. I know what he means and so does my 5 year old grandson and 90 year old mother.

[walbut]

SPHLC/Nutloose

The handle operates a mechanical linkage that pulls a sear out of the firing unit. There will be a small amount of free play or backlash in the system. The majority of the the handle travel upwards, pulls the sear, which is a wedge shaped plate through the bottom of the firing pin. As the sear is withdrawn it gradually moves the firing pin away from the cartridge, compressing the spring on the firing pin. When the sear is fully withdrawn the firing pin is no longer restrained by the sear and under the force from the spring, hits the cartridge, starting the ejection sequence. I guess if the handle is partially pulled and then released, the sear will reseat under the forces from the firing pin spring. It might be possible to reach a situation where the sear is resting on the crest of the ramp and is then in a metastable condition and could go either way with the slightest force, one way back to safe, the other way to fire the seat. This is just an engineering guess, I have never tried to reproduce this situation, but I bet a lot of others have over the last couple of years.

As a follow on, the T Mk 2 and later Hawks has a 'PINS' caption on the CWP. If I remember rightly it illuminates if the pins are left in with the canopy closed. It was introduced to try and prevent one of the other hazards associated with seats, leaving the safety pins fitted during flight. The pin operates a microswitch behind the fitting into which the handle seats. If the pin were fitted when the handle is partially pulled, it would not give a PINS warning at the appropriate time. I guess when the crew reach the end of the sortie they probably shut down the electrics before fitting the seat pins so it would not show up at that point. On the next sortie though, after closing the canopy the crew would expect to get a PINS caption but would not if the handle were not in the correct position. It's not how the system is intended to work and its not a very robust means of warning the handle is not safe, even though the pin is fitted. However it is progress in some senses.

Walbut

[NutLoose]

Thanks Walbut for clarifying the operation, I remember a famous picture from years past of some aerobatic team doing a manoeuvre, the safety on that seat was a lever and you could plainly see in the shot that on one of the seats, the lever is still in the safe position. I have looked for it, but alas cannot find it.

[Mrmungus]

Mortmeister PM sent

[Background Noise]

Keep up at the back Nutty - that has been mentioned even in this thread a few times now. #210, #212 and #297 at least.

[Willard Whyte]

In the case of ejection seats with 60 years of development I will firmly put my hand up and say YES.
In my mind every ejection seat that makes it into production aircraft MUST be right first time. Creationist? maybe. I'm also someone who worked on and around ejection seats for many years.

If it were right first time there wouldn't be any need for 16+ Mks of seat (from MB alone).

Everything can be improved, subject to experience and technology. The requirement will always be there, of course.

[SirPeterHardingsLovechild]

While we're waiting, some definitions from the


"Service Inquiry report into the accident involving Royal Air Force Aerobatic Team (RAFAT) Hawk T Mk1 XX179, near Bournemouth on 20 August 2011."


Cause: An event that led directly to the accident


Contributory Factor: A factor which made the accident more likely


Aggravating Factor: A factor which made the outcome worse


Other Factor: A factor which was none of the above, but was noteworthy in that it may cause or contribute to future accidents


Observations: An issue that was not relevant to the accident but worthy of consideration to promote better working practices


Military Aviation Authority | MAA Service Inquiries (http://www.maa.mod.uk/about/maa_service_inquirie/index.htm)

[NutLoose]

Background I know the one in the headrest that was mentioned, but I'm sure the one I was thinking of was a sidebar outboard of the headrest.

[dervish]

SI report this week?

[EGLD]

I also repeat the question. Were ANY OTHER BOLTS FOUND PINCHING THE SHACKLE during the fleet checks or was this one the only example ?

It's my understanding that, when the rest of the Red Arrows fleet were checked, none of the drogue shackles were found to have been overtightened like Lt Cunningham's.

This guy was seriously unlucky.

[lj101]

It's my understanding that previous ejections (involving this Mk of ejection seat)had only succeeded because they were not zero zero ejections, and that MB were allegedly aware of this.
All rumour of course.

[tucumseh]

I also repeat the question. Were ANY OTHER BOLTS FOUND PINCHING THE SHACKLE during the fleet checks or was this one the only example ?


Excellent question, but worth pointing out a related MoD policy (Adam Ingram, when Min(AF), and successors) that a trend failure can now only exist in the tail number in question. That is, it may be considered a trend if it occurs more than once in a tail number, but not if it occurs once in every aircraft in the fleet.

Interesting concept, which explains much, with roots in the Chief Engineer policy of 1991 to cease all fault monitoring tasks. That recurring date again.

To be fair to the MAA, they haven't said they agree with this; but neither have they disagreed and continue to support the DE&S authors of the Ministerial brief. (Your balls hurt if you sit on the fence too long).


I disagree by the way.

The main point here is that the fleet inspection occurred after the accident, yet the problem was known beforehand. Exactly the same happened prior to Tornado ZG710/patriot shootdown (2003) - 2 dead - so lessons aren't being learned. Don't be blinded by any MoD spin that no other faults were found. The death was avoidable and MoD policy militated against avoidance.

[airsound]

SI report this week?The MAA tells meThe Service Inquiry report will be released on 6 FebIt should appear on Military Aviation Authority | Home (http://www.maa.mod.uk)

In answer to a question about redaction, they have also said (my bold)
It is MOD policy to redact all Service Inquiry (SI) reports, in accordance with the FOI Act, prior to release. This includes the removal of personal information, and Operational or commercial information deemed too sensitive to release into the public domain, amongst other things. In practise, none of the exemptions in the FOI Act applied in this case so the report will be released unredacted aside from the removal of a small amount of personal informationairsound

[Blacksheep]

a trend failure can now only exist in the tail number in question. That is, it may be considered a trend if it occurs more than once in a tail number, but not if it occurs once in every aircraft in the fleet.
On a single tail number, a single failure is an event, a second failure may indicate a trend but a third failure is a repetitive defect and in civil aviation is subjected to special measures. Three similar events across a fleet is a Reliability Issue and reliablity analysis is involved. The "trend Line" for the fleet is a time-related matter. Three events in three months would give a steep trend line: three events in two years would not change the slope.

[tucumseh]

Blacksheep

That all sounds familiar.

The debate at the time (given we tried to ignore AMSO's edict) included an interesting question. If the fault was first noticed on the Reference or Sample system, did that count as the first "event"? The answer was, Reference - Yes (because it is held at 24 hours readiness for front line use and is at, or beyond, the In-Service Build Standard) and Sample - No (because, like Hot Rigs, it has known unserviceable LRUs applied to it, so false data is inevitable, and it is almost never at the In Service standard).

The reason I remembered this was because if Martin Baker uncovered the possible over-tightening issue, it may have been on their Reference seat. If that were so, there would be a very formal way of reporting and investigating; quite different from someone, for example, just thinking of the risk or spotting an error in a tech pub.

I still think it inconceivable they did not inform MoD. MoD have admitted so many times now their entire system was is disarray. My bet is MB sent the paperwork to a defunct department/address and it was thrown in file 13. I certainly recall many AMSO and ASE sections at the time changing their titles but retaining their addresses. Anything addressed to the old title was binned, even though it got to the right person in the right office. MB's contract would tell them who the point of contact was. That would take months or even years to be amended. But I'm sure the SI, Coroner and CPS explored all this. :rolleyes:

[EGLD]

It's my understanding that previous ejections (involving this Mk of ejection seat)had only succeeded because they were not zero zero ejections, and that MB were allegedly aware of this.
All rumour of course.

Isn't that accepted/evidenced by the fact they had told other air forces that their was the potential to over-tighten the bolts on the drogue shackle?

I thought the issue was more that the RAF had not officially been told, and that there was "no logic" for this?

"my understanding" :rolleyes: is that the RAF were aware, but that it was information that was verbal and "understood" and so nothing official in any manual

Seems like a case of poor communication more than anything else as far as MB are concerned. What would be the reason for them to withold information that the seat could fail in zero/zero conditions if this bolt was over-tightened, when they had admitted as such to many other organizations?

Mods/upgrades/advisories are carried out constantly as issues are found on seats, why would this issue be any different?

[tucumseh]

What would be the reason for them to withold information that the seat could fail in zero/zero conditions if this bolt was over-tightened, when they had admitted as such to many other organizations?

Mods/upgrades/advisories are carried out constantly as issues are found on seats, why would this issue be any different?


Lacking precise detail (because MoD omitted it in court and in all likelihood no-one knew to ask), the key is a proper contract being in place. This has not been MoD policy for over 20 years (which coincides with the reported timeframe) and, as I said in a previous post, there are well documented cases of companies giving up and refusing to work for nothing. If or when a contract was later let, the gap was never filled retrospectively, which translated into missing information in tech pubs.

Not saying this is what happened here, but it is the starting point. It is entirely possible that MB sent the information, but there was no-one in post to process it. There is still much to do, and many MoD staff involved, after the initial notification hits MoD. The various ART reports of the early-mid 90s are consistent in this area - it was not funded and much work was not done.

[Flight_Idle]

I don't mean to speak out of turn here, but all these posts about complex administrative details, seem to forget that it's the technician at the 'Sharp end' who really has the final say in flight safety (Along with those who actually have to fly the machines)


A post on this thread awhile back struck a chord... If it had been a junior erk sat in the seat when it fired, I think there could possibly be a general assumption that it was his, or her fault.


It appears to me, that flight safety is very 'Top down' these days, given the plethora of administration, publications & the general dismissal of experience of those on the 'Coal face'.


It's a two way thing in my opinion, those on the 'Coal face' can't usually work out the fatigue life of an airframe for example, yet they know the inner workings to a fine degree.


It's the idea of complex administration, with guys on the ground 'Robotically' following instructions, which is wrong on so many fronts.


This post is somewhat off topic, but was prompted by all the posts about the 'Top down' administration.

[Plastic Bonsai]

Walbut:
"As a follow on, the T Mk 2 and later Hawks has a 'PINS' caption on the CWP. If I remember rightly it illuminates if the pins are left in with the canopy closed. It was introduced to try and prevent one of the other hazards associated with seats, leaving the safety pins fitted during flight."

I recall this being discussed in the early '90's and originated from a test pilot, familiar to many here, who made the dreadful discovery that he'd flown a sortie with the pins still in (though he wanted it linked to the engine turning). He had gone on about this until he retired and just couldn't get anyone to implement the idea. I've often thought that there is a general ethos in aviation to leave stuff alone for some unfathomable reason and it is a real struggle to get any innovation or improvement made until an accident or incident forces action.

Perhaps an improvement or a correction is seen as an admission that it wasn't perfect in the first place. In the real word nothing ever is.

[longer ron]

The 'pins left in ' scenario should not happen with most RAF Hawks - as most RAF Hawks have the modified pin stowage on the port glare shield,thereby giving the grouncrew an excellent view of pin location.
The original pin stowage on the left canopy longeron was not as safe because if the pilot forgot his pins - it would not really be obvious to the groundcrew !
Ironically the Reds have the canopy stowage because the 'smoke on' indicator lights are up on the glare shields.
There is one other UK based hawk with the canopy pin stowage in the rear cockpit because of lack of space on the glare shield.

[tucumseh]

It's the idea of complex administration, with guys on the ground 'Robotically' following instructions, which is wrong on so many fronts.With respect, I disagree. The entire system has to work properly. What I talked about above is an important engineering requirement, (and should be) managed exclusively by experienced engineers who are required to have worked at (at least) 2nd or 3rd line on the range of aircraft and/or equipment they now find themselves with the airworthiness delegation for. In fact, this process is so exclusively an engineering discipline, it is the one area of MoD business where the engineer is required and permitted to negotiate and let contracts. (Although adminers, like Commercial, don't like hearing this). It is also the only time a company employee's appointment is formally controlled by MoD, and he is given financial delegation and the authority to commit MoD funding without recourse to the MoD Technical Agency - all in the interests of safety.

This process set the standards for the sharp end to comply with, and the primary output is a verifiable Safety Case, without which the aircraft cannot fly. One of the problems in this accident was a complete breakdown of this process, and it is vitally important to understand why because it is indicative of systemic failures. One of the reasons, almost certainly, is the reduction in engineering posts (something mentioned at the Inquest, and not confined to front line - in fact, front line have survived longer than most).

I think the underlying causes of this accident are going to be complete no-brainer. The real problem may be that MoD no longer have anyone junior and experienced enough to understand. They have plenty of senior staff who don't begin to understand. It certainly wasn't reported that anyone came remotely near the truth in court, but perhaps tomorrow we'll see if the SI got there.

[Background Noise]

The 'pins left in ' scenario should not happen with most RAF Hawks ………...

The old pin stowage is quite visible from the outside. The reason it was moved was to put it more into the pilot's view to try to prevent him forgetting it.
It was mentioned at the inquest that the ground crew had reminded him to stow his pins.

[Flight_Idle]

I have no problems with what you say Tucumseh.


Instructions are there for a reason, but if wrong, the guy on the coal face should stop & report it.

[tucumseh]

Flight Idle

Absolutely spot on.

But to be fair to maintainers throughout MoD and industry, if the powers that be stop funding MF765s (Unsatisfactory Feature Reports) altogether, then it is natural that an apathy will will set in because one never gets an answer. Time after time this system failure has been escalated up the Star ladder by the Inspector of Flight Safety; if they ever bothered to respond it is along the lines of "shoot the messenger". The same people succeed in hiding their failures because they dictate the scope of any investigation, thus judging their own case, which is why MoD only looks at the final act (the pilot or maintainer). How many BoI/SI reports have cited "Organisational Fault" as a factor? Nimrod XV230 came close (ACM Loader) but didn't use the words. The rules should require a positive statement; not an implication that just because they don't mention it everything is ok.

[NutLoose]

I seem to remember when the first Chinooks came into service the manuals were printed on yellow paper, as they were used and problems were found they were amended and they came out in white,that way you could see pages that needed checking against the aircraft, and those that had been corrected, eventually we ended up with a working copy.

[longer ron]

The old pin stowage is quite visible from the outside. The reason it was moved was to put it more into the pilot's view to try to prevent him forgetting it.
It was mentioned at the inquest that the ground crew had reminded him to stow his pins.

Sorry to disagree but realistically the 'new' stowage is as much for the groundcrew as the aircrew,if the pins are not in the glare shield it is very apparent to the start crew,also very easy to do a positive check !
The trouble with the 'old' stowage was that if the pilot forgets - and the start crew does not notice/or distracted - then it does not really stand out...the pins show very well if stowed but there is no highlight if not stowed !

[tucumseh]

At #236 I said;


59 recommendations in the SI report. All accepted apparently.

I wonder how many fall into the "mandated policy anyway" category. Most in the Nimrod Review did.


Answer now available. The vast majority. :ugh::ugh:

"Ensure safety critical components meet design specification"

"Ensure risk are tolerable and ALARP"

"Ensure project teams have a robust and auditable method of tracking, reviewing and managing airworthiness decisions"

"Ensure the project team maintains safety cases"

"Ensure the document set accurately reflects maintenance procedures"


And so on. 1st year apprentice stuff throughout. Anyone with more experience should be utterly embarrassed at having to be reminded of this. The very fact they have to make such recommendations means very senior heads should roll over this. And yet a year ago the CPS said there was insufficient evidence.... Time to reconsider.

[airpolice]

Military Aviation Authority | MAA Service Inquiries (http://www.maa.mod.uk/about/maa_service_inquirie/index.htm)

Nothng yet

[airsound]

At post 369, I said, about the SI report,It should appear on Military Aviation Authority | Home (http://www.maa.mod.uk/)It hasn't appeared there yet, but it is at https://www.gov.uk/government/publications/service-inquiry-into-the-accident-involving-hawk-tmk1-xx177

It apparently had to await a ministerial statement http://www.parliament.uk/documents/commons-vote-office/February_2014/6th%20February/4.MOD-RedArroxHawkXX177.pdf
although for the life of me I can't imagine why this work of two years plus had to await the totally anodyne remarks of a defence minister before being released to the rest of us.

airsound

[dervish]

I hope everyone here reads this report and never again has the brass neck to criticise anyone who stands up for aviation safety. It is far worse than Haddon-Cave's pussy footing attempt. By all means read the Nimrod Review but come to pprune for the real truth. :mad:

[Alber Ratman]

A comprehensive set of documents as usual that left no stone unturned.

[tucumseh]

A comprehensive set of documents as usual that left no stone unturned.

Well, apart from the one that the perpetrators crawled under.

[BEagle]

I find it quite unpardonable that officers selected to maintain the standards described in 1.4.5.2 should resort to the blatant lying and cheating described in 1.4.5.10 and 1.4.5.11.....

[Willard Whyte]

Indeed Beags.

One wonders, under (perhaps) other circumstances, what the penalty for falsifying legal documents is.

[NutLoose]

I am surprised they took the seat all the way to a civilian police station with the possibility of it being disturbed, one would have thought they could have quarantined it on site, is that the norm now?

Still reading the rest.

[tucumseh]

One wonders, under (perhaps) other circumstances, what the penalty for falsifying legal documents is.


Precedent.... Chinook HC Mk2 RTS, signed by Beagle's favourite officer.

According to the Air Force Act such falsification carried (up to) a 2 year prison sentence. (DE&S & Ministers say it is an offence to REFUSE to make a false declaration).

The CPS say there is no evidence. Don't tell me they never got to see the SI report?

[Willard Whyte]

Whilst not in any way condoning the falsification, one can only imagine the pressure 'from on high' to keep RAFAT, and indeed other operational etc., flying going under ever increasing budget strictures.

A can-do attitude has its place, no doubt, but are we merely seeing the tip of the iceberg? Sadly I don't for one nano second think that the dodgy practices uncovered as a result of this tragic accident are limited solely to the way the Red Arrows conducted their daily procedures.

I hope a few of the RAF's leaders at line level now feel empowered to turn around and say "NO" without fear of repercussion. It's the only positive that may be gained from this sorry episode.

[Flight_Idle]

Having read through the SI, I'm sort of gobsmacked about the simple nuts & bolts etc shown in the photos. It seems to me, to be simple 'Ground level' stuff, which the top end of the hierarchy cannot be expected to understand.


I stand my ground when I say that 'Robotic thinking' is not a good idea, when following instructions.


I still think that the top of the hierarchy can plan as much as they want, but it still comes down the person carrying out the instructions to use a good dose of common sense.


I'm going to have to re-read the whole lot, because it just seems so strange.

[Alber Ratman]

Having read the rest of the report, Tucumesh, it paints the whole of the RAFAT procedure and training structures for both aircrew and ground crew in a terrible light with fingers that need to be pointed at people higher up the chain (to I assume you refer to as the people who disappeared under the rocks). Can of worms opened again.


My present employer would lose its AOC with such transgressions.

[SirPeterHardingsLovechild]

Previously on this thread, I was struggling with the jump that had the seat unsafe for 4 days (and brought in all the missed chances), and as I suspected the investigators have gone from
1.4.2.18. ...most likely moved to an unsafe condition...
to
1.4.2.14. ...it was concluded...


But I can see that the boffins have done a thorough job before they 'concluded'. Not proven, but pretty compelling.




So if the boffins are to be believed without question:-


1.4.2.8. 60 Newtons? To fire the seat by pushing the handle forward. Is that broadly similar to a force of 60kg? 75% of his bodyweight? (I know about force and mass etc, but broadly speaking for the man in the street)


Lastly from me for the moment. If the seat was unsafe for 4 days, (unless I have missed it) the investigators have failed to document every event that happened between then and the accident. It seems to me that ejection seat pin checks up to this accident may have been a cursory glance, but I would therefore make a distinction of (an engineer) leaning into the cockpit to check something, or to actually sit in the seat.

[tucumseh]

which the top end of the hierarchy cannot be expected to understand.

They were given enough warning by, among others, the Inspector of Flight Safety. Are you saying the RAF Chief Engineer did not understand basic engineering, or could not read his letter of airworthiness delegation, or the ones he handed out to his subordinates?

[Willard Whyte]

1.4.2.8. 60 Newtons? To fire the seat by pushing the handle forward. Is that broadly similar to a force of 60kg? 75% of his bodyweight? (I know about force and mass etc, but broadly speaking for the man in the street)

60 Newtons is roughly (just over) 6kg under (Earth's) gravity. Not much, in other words.

(Newtons (N) = Mass (kg) x force, or acceleration if you will (G, or m/s2))

G being equal to ~9.8 m/s2 on Earth

Lastly from me for the moment. If the seat was unsafe for 4 days, (unless I have missed it) the investigators have failed to document every event that happened between then and the accident. It seems to me that ejection seat pin checks up to this accident may have been a cursory glance, but I would therefore make a distinction of (an engineer) leaning into the cockpit to check something, or to actually sit in the seat.

Unfortunately, if one accepts that 'the boffins' are correct, we probably know how the chain of events unfolded, but are unlikely to know why, to anything approaching 100% certainty anyway.

[Photoplanet]

Quoting SPHLC:

1.4.2.8. 60 Newtons? To fire the seat by pushing the handle forward. Is that broadly similar to a force of 60kg? 75% of his bodyweight? (I know about force and mass etc, but broadly speaking for the man in the street)

No... Approximately 10 Newtons per Kg. Kg is a downwards (weight) force, influenced by gravity. Newtons are a measure of force, in any direction. 60 Newtons would be about 6 Kg of force.

[goudie]

ejection seat pin checks up to this accident may have been a cursory glance,

As the SI states, people checking the seat saw what they expected to see, when looking into the cockpit. The handle apparently fully down and the pin apparently in it's correct position
Familiarity does breed contempt.
The SI is very sober reading.

[SirPeterHardingsLovechild]

Thanks all, I'll leave my schoolboy error there for all to see rather than make nonsense of subsequent posts

[Dominator2]

I have just read the SI Report into this accident. Although some of the Findings do not directly contribute to the accident they are a reflection of the appalling way in which the Reds Squadron was run at that time. The lack of discipline that was displayed in so many areas is an indictment of how the Squadron was run. The lack of Supervision from Boss, Wg Cdr, and Commandant shows a total lack of awareness and interest in the day to day running of the Sqn.

I was on a “small unit” for 12 years of the 40 that I served and know of the temptations to short cut the system.Particularly when in a privileged position such as the Reds it is possible to become arrogant and become “above the law”. I thought that after the investigation into “small units” in the early 1990s that these lessons had been learnt. The Reds do a great job in the air but there is more to aviation than pulling 6G or being 4 feet away from 8 other aircraft in close formation.

The present day service, in my opinion, does not teach discipline. Discipline is not something learnt on a parade square or moving pine poles. It is that ability todo the correct thing on all occasions, despite any outside pressures. That translates into strapping in correctly,always doing safety checks correctly, switching OFF you’re your mobile at the Out-brief,completing CT as laid down and completing the records truthfully. I could go on,but the lesson is there.

The Service needs to have a long hard look at itself. This unfortunate accident has been waiting to happen. Despite all of the great things that the Service has achieved in the past 15 years, that is when the rot set in. In the brave new world of the RAF some of the basics have been lost. The most important of those is discipline!

[NutLoose]

Well that washes their laundry in public so to speak... It makes grim reading, you can bring all the rules and regulations out in the world, but if you ignore them, they are just so much toilet paper.
Surprised the Babcocks course is deemed unsuitable for the RAF engineers bearing in mind I bet most of the civilian engineers will be ex Airforce anyway, and one would have thought a course that doesn't quite hit the mark is better than no course at all.
Cannot believe they were illegally massaging their flying currency requirements etc either...

[Photoplanet]

Just finished reading the report... The facts can be understood, an unfortunate series of errors, compounded by an engineering anomaly... Either one may have been mitigated, in different circumstances, but when combined were sadly incompatible with survival...

The report went far deeper than I would have expected, into the culture of the 'Reds', I hardly dare comment, based on what I have read.

[JFZ90]

Slightly off topic.

I couldn't find the detail in the report, but what happened in the inadvertent hawk ejection from 1983 that was referred to?

[Bronx]

Speaking about the findings, retired Air Vice Marshal Jerry Connelly, said: "This isn't something that has crept in over the past couple of years - I suspect it goes much further back in time - and whatever the structure of the air force there has been a chain of command at the top, monitoring and allowing the team to actually perform."
He added: "I cannot believe this has all come as a big shock to them and its hard to understand why they were not doing something more active to change that drift."

The British press seem to like going to Retired Air Vice Marshal Jerry Connelly for a quote.

Was he disappointed not to become an Air Marshal?
Is he now a 'consultant' earning money in the civvy sector?

:confused:

[JFZ90]

Well, I've only skimmed the report, and it is impressively detailed as usual.

I can't help thinking:

- this accident was truely tragic, as stated in the report
- it does seem to me to be mainly technical in nature, the ops stuff is concerning, but largely unconnected with the actual incident IMO.

Final thought - don't know how many lives the Mk10 has saved, but must be up there as one of the most successful live savers ever. That shouldn't be forgotten.

[Bronx]

the ops stuff is concerning, but largely unconnected with the actual incident IMO
I agree.
The Dominator probably won't.
Discipline!
That's what these young chaps need. More discipline!

http://image.shutterstock.com/display_pic_with_logo/525955/525955126415186730/stock-vector-cartoon-vector-illustration-grumpy-old-man-45014632.jpg

[airpolice]

- it does seem to me to be mainly technical in nature, the ops stuff is concerning, but largely unconnected with the actual incident IMO.

I think the important point there is that the "ops stuff" will become very much a feature of another incident down the line if it is not dealt with now.

The constant thread running through accident reports is that the paperwork was wrong.

Only two things can cause this.

Either:

A Being slack with paperwork makes you crash.
or
B People who are slack with their paperwork are more likely to crash.

It may of course be that all squadrons are as shabby at keeping in line, but if that's the case, why?

I've been reading some more service inquiry reports, and apart from the appalling grammar and spelling errors, (very like the AAIB reports) there is that ever present history of errors leading up to the crash.

The fudging of hours for IR recency or CT hours might have no bearing on this particular tragedy, but what kind of culture is it exposing?

What's it going to take for someone to have the balls to find and discipline the officers who failed to find the shortcuts? I know it will not bring Flt Lt Cunningham back, but it might well keep Flt Lt Bloggs alive next year.

Since DLT can be put in the dock for "allegedly" feeling up a girl on Top of the Pops 40 years ago, surely even a Group Captain can be held responsible for his actions (or lack thereof) as a Squablin Bleeder five years ago.

[Flying Lawyer]

The constant thread running through accident reports is that the paperwork was wrong.

Only two things can cause this.

Either:

A Being slack with paperwork makes you crash.
or
B People who are slack with their paperwork are more likely to crash.

I disagree.
My experience, based upon reading hundreds of accident reports over a few decades, is that investigations almost invariably disclose inaccuracies in paperwork.
However, the same is true of investigations for other (non accident) purposes.
It is extremely rare that very close scrutiny of any human activity fails to disclose inaccuracies in paperwork.


In relation to accidents:
Far more often than not, the inaccuracies had no bearing whatsoever, directly or indirectly, upon the accident.


FL

[Fox3WheresMyBanana]

Agreed, sort of; from my time as a Station Flight Safety Officer, admin errors were at least a minor contributory cause in over 30% of accidents, and occurred in both BoIs I had to organise.

[airpolice]

So, Flying Lawyer, would Your paperwork stand up to scrutiny then?

If, the last time that you piloted an aircraft, you had been "ramp checked" would you have failed to be able to show compliance with the regulations?

[airpolice]

Fox3, do you think that if the culture is to allow the paperwork to be "there or thereabouts" then the spirit of other checks and balances may be cast aside as well?

[Fox3WheresMyBanana]

The admin errors can occur at any point in the system, from Orders, manuals, even unofficial (but highly useful) 'guides'. Was my paperwork ever in error? Not when I or anyone else formally checked, no. But I am not so arrogant as to claim it never was on all the occasions I wasn't checked. OTOH, maybe that's why they made me a Station Flight Safety Officer!

[airpolice]

maybe that's why they made me a Station Flight Safety Officer


Or....................

Maybe that's why you didn't feature in a Service Inquiry.

[Fox3WheresMyBanana]

Airpolice - It's a risk, certainly. In my time (80s, early 90s), accidents occurred that showed the risk is higher in small/unique units. There is always the balancing factor that the aim of an Armed Force is not just to complete paperwork. I can remember certain paperwork stats that were literally impossible (because certain aircraft/equipment no longer existed), yet insisted on by NATO. Do you lie and fill in the 'We've done it box', or cause a whole load of aggro (which won't fix the problem) and tell the truth? What most (and I) did was to lie, but make a special point not to let lying become a habit.

[Flying Lawyer]

So, would Your paperwork stand up to scrutiny then?
I assume you are referring to paper-work/records I keep during the course of my work. I couldn't guarantee that close scrutiny would fail to find any errors. From time to time, I've found errors or had them pointed out to me.


If, the last time that you piloted an aircraft, you had been "ramp checked" would you have failed to be able to show compliance with the regulations?
I believe I would have been able to show compliance. However, I'm only a self-fly hire PPL so it's a relatively simple process.


My fundamental disagreement is with your proposition that "Only two things can cause this."
I have seen instances where sloppy paperwork has been an indication of a sloppy operation/pilot, but it doesn't by any means necessarily follow.


FL

[Two's in]

- it does seem to me to be mainly technical in nature, the ops stuff is concerning, but largely unconnected with the actual incident IMO.

Or answer (b)

The "ops stuff" was indicative of the organisational failings that had happened over a number of years. Tragically, the lightning rod for these failings was the technical failure of the drogue shackle. The "ops stuff" that got the poor soul into this position are manifest throughout the report. There were numerous opportunities to break the chain, but they were all missed. The avoidance of poor seat pin drills, incorrect seat stowage post flight, ineffective engineering oversight and a different flight safety ethos could all have taken fate on a different course that day, but because all those factors existed, the drogue shackle failure proved to be fatal. The "ops stuff' got him to the scene of the accident as fast as any other cause would have done on the day.

[Fox3WheresMyBanana]

I'm with FL on this one.

AirPolice's point.
b. Pilots who are slack with paperwork are more likely to crash,

is true in my experience,

but there are a very large number of other factors, as the Board found in this case.
At the root, this accident was caused by it being not generally known that the Seat Pan Handle could be partially raised (I have about 800 hrs on Mk10 seats, and I didn't know this till now) and it not being at all easy to see this, and that the scissor shackle bolt was overtight by 0.009 inches.

[airpolice]

FL, perhaps I should have made the Tounge in Cheek aspect of my "only two things" comment clearer.

Obviously there can be many causes, and sometimes no connection. But who can really believe that Coiln Macrae would have survived until today if he'd carried on flying with such scant regard for the rules?

Like you, I just drive puddle jumpers belonging to a variety of other people. I was referring to the simple paperwork that we are subject to.

One outfit that I hire from have never seen my licence or logbook. One FI there did ask me one day if I had it with me, and on being told that it was in my bag, he was satisfied.

Another operator is at the other end of the scale and on returning there after a break of almost three years, to the club where I passed my skills test, I was required to produce, as part of my check ride, my licence, log book and medical. I'm not afraid of being asked to produce it instantly, because I can.

This club keeps a note of all relevant expiry dates for all pilots and we are all subject to making public our recency compliance, for all club members to see.

My point about the accident reports is that there is a high incidence of "the deceased was flying without the right paperwork" so how many others are doing the same but we don't hear about it until they are dead?


The SI into the incident at Scampton has shown some big lapses in management of the regulated documentation. How many times will this need ot come up before the rest of the RAF takes a good look at how they are doing things?

Perhaps nobody cares because they are not going to have their bum felt for it even if they do get caught. No amount of looking at squadron flying hours and IR recency or dual checks on the aircrew woud have made the seat work. That's no reason not to flog someone for letting the side down.

[JFZ90]

yes, its very sad - you look at the SPH now and think that is an obvious issue, but its clear it wasn't obvious for years for hundreds of users. Easy in hindsight.

similarly with the shackle, its obvious when you look at the design that it shouldn't be tight enough to pinch, and actually it seems clear that this was kind of known for over 20 years, but sadly on this occasion it was also missed. The tech pubs should clearly have spelt it out, but given the consequences, it is unfortunate that the risk of pinching was not designed out in the first place. Easy in hindsight.

[MAINJAFAD]

I couldn't find the detail in the report, but what happened in the inadvertent hawk ejection from 1983 that was referred to? There were actually two in 1983 within a week of each other. One was a Red that suffered a wire strike with a Liney in the back who banged out without waiting for Eject, Eject, Eject (he did pull the handle). The other one was a Fighter Controller whose 'Red connection' was that he shared the same first name as Red 2 in Star Wars who banged out of a TWU Hawk off the coast of East Anglia. He claims the seat just went off after he was rescued (everybody I personally know who knows about it think otherwise), however seeing the seat was never recovered nobody will know. In a long archived thread on here, BEagle recounts seeing the Hawk land at Wattershambles with the ejection gun tube sticking out the back of a broken rear canopy with quite a bit of damage to the fin. While somebody else recounts what the Hawk was doing when the seat and scopie departed the aircraft (2 ship figure of eight pattern visual CAP if memory serves).

[Flying Lawyer]

My point about the accident reports is that there is a high incidence of "the deceased was flying without the right paperwork" so how many others are doing the same but we don't hear about it until they are dead?
I don't know, but I suspect most of them eventually die of natural causes/old age.
I don't accept the validity of the link you seek to make.


That's no reason not to flog someone for letting the side down.
IMHO it's essential to keep a sense of proportion.
Failings which emerge during the course of a fatal accident investigation should not be dealt with more harshly simply because there was a fatal accident.
If a failing is proved to have caused an accident, or proved to have contributed to it, different considerations apply. (NB. Proved. Not speculation that a failure to enforce or comply with rules/regs might have contributed in some indirect way to the accident.)

Much has clearly been learned from the investigation into this tragedy, and there are some findings of systemic failings. I don't share your desire to to try to find people to punish. (Or scapegoats.)


FL

[2 TWU]

Re the Fighter Controller leaving inadvertently, yes, initially he said he hadn't pulled anything but later confessed to "fiddling" with the handle.

[lj101]

Much has clearly been learned from the investigation into this tragedy, and there are some findings of systemic failings. I don't share your desire to to try to find people to punish. (Or scapegoats.)


I agree. Human beings make mistakes. What happened, why did it happen, what can we do to prevent it happening again. Open honest reporting to break that chain.

[Just This Once...]

Re the Fighter Controller leaving inadvertently, yes, initially he said he hadn't pulled anything but later confessed to "fiddling" with the handle.

This was my understanding too. With the benefit of hindsight one wonders why the 3 positions of the Mk10 SPH did not come clear during the investigation that followed, even without the recovery of the actual seat. Clearly I am not suggesting a causal link but there was an 'in-depth' investigation into the seat pan firing mechanisms (well, that was the understanding at the time).

I have flown the Mk10 in 2 RAF types and I remain stunned that I knew so little of the potential risks and that my own training and my own checks were ineffective. I did however completely understand that the signing for events not actually completed was a serious service offence.

[tucumseh]

Human beings make mistakes. What happened, why did it happen, what can we do to prevent it happening again. Open honest reporting to break that chain.

If the human beings have been told of the likely outcome of their policies, the deaths have come to pass and they continue with their policies, are those individuals or the system they have created and perpetuated, fit for purpose?

I wholeheartedly agree with your comments as applied to the vast majority, but there is a malign controlling influence at the heart of all these accidents, and they are continually allowed to judge their own case.

We should never lose sight of the fact MoD will always try to compartmentalise and localise the issue. The simple fact is, we've been here before and, yet again, the systemic failures have their roots in the same policies.

Neither should we lose sight of the fact the SI looks at the cause of the incident (the inadvertent firing); the subsequent death is an unfortunate outcome. The Coroner, on the other hand, looks at the cause of death - which focuses on chute failure. MoD's focus, the firing, conveniently directs attention away from the long term systemic failings and the DIRECT links to previous accidents. The SI does a good job, and points to this, but is not allowed to dwell or even offer an explanation for these failings. There are many recommendations, but no explanation as to why they are necessary. Much to MoD's relief, I imagine.

I'd also like to say that, while I'm critical of the MAA hierarchy, who today are part of this "controlling influence", these failures are so long term (1980s) and deeply embedded in MoD policy and practice, that it would be nigh on impossible to eradicate them in the 4 years the MAA has existed. In that four years, we have seen the instigators of the policies even write to the press defending themselves, and their exact words repeated in the House by the Secretary of State. Being MAA DG under that weight is a crap job. But at no point did either MAA DG write to the SofS and say "You're being lied to". Which is why it would be better off outwith MoD. As you say, Open honest reporting to break that chain is required.

[thefodfather]

For me, one of the key things that is needed is to extend the concept of Just Culture into the organisational context. Whilst there have been (some) improvements in the implementation of Just Culture to those at the pointy end of things, the process stops at those directly involved in the occurrence itself. If Just Culture, and all the other elements of culture that goes with it, was extended throughout the organisations involved in the causal factors hopefully the individuals making the decisions will feel more protected when they do things that are justified and with the best of intentions. Likewise, should anyone choose to do something less honourable, they would be aware that they were crossing a defined "line in the sand" for which they would be held accountable.

The challenge of course, would be for the MAA as the Regulator to enforce such a process and audit its application.

[BEagle]

FL, I really cannot be so dismissive of the pilots' 'paperwork'.

The deliberate falsification of continuation training, instrument flying and instrument approach records is a wholly different matter to mere forgetfulness.

It's the difference between forgetting to submit your income tax return (Jack Swigert, Apollo 13) and making a false declaration.

In PPL terms, it's the difference between forgetting to get your Class Rating revalidation signed by the due date and deliberately 'Parker penning' the necessary hours to revalidate by experience.....

If, as seems likely from the SI, there was a culture amongst RAFAT to consider such lying and cheating normal, then that to my mind indicates a cavalier attitude towards operations in general. Which is reinforced by the wholly pointless abbreviated 'timeline' from brief to take-off and the non-adherance to mandatory Hawk FRC procedures.

[lj101]

The deliberate falsification of continuation training, instrument flying and instrument approach records is a wholly different matter to mere forgetfulness.

This matter is rumoured to being dealt with via a court martial in the near future.

[airpolice]

Beagle, I fear that you are up against a brick wall there.

There is a sense of the "justice" that we see in RTA offence prosecution there. I admit it is a difficult balance, but take this example.

Speeding, in a defective car, loss of control and car collides with a wall. No injury but extensive damage to property.

Same scenario, but two pedestrians between car and wall, one dead & one maimed and in need of extensive support and care for the remainder of their days.

The actions of the driver are the same in each case, but will be dealt with differently by the court.

All's well that ends well seems to pervade the GA community with regards to documentation, and now we see evidence of it in the Reds as well.

How on earth can the Reds have continued to operate in this fashion after another SI pointed out the same failings a few years before?


Tucumseh is forever bangining on about VSO conspiracy to cover up unlawful instructions which have cost lives, and we all need people like him to speak up. I had thought, and hoped, that such practices were not happening at squadron level, but it seems to be so.

[Easy Street]

Obviously it is regrettable that military airworthiness provision continues to fall short of the standards that once prevailed, and I hope that some of the evidence presented plus the convening cuthority's comments help tuc et al continue to move their campaign forward. However, as tuc observed, the report does not make airworthiness failings its focus; rather than see this as obfuscation, I see it as a reflection of where the truly shocking failures in this accident occurred.

Now that the report is out I'll be more blunt than in my earlier comments. Airworthiness provision cannot alone deliver safe flying operations. The operating outfit has a responsibility to provide a certain level of personnel competence and appropriate procedures because even the most airworthy equipment will fail if abused. In this case, technical shortcomings went unidentified; how, exactly, was DE&S supposed to identify them until one or the other was laid bare?. That almost falls into the 'bad stuff happens' category for me, so the truly shocking aspect is the degree to which lax supervision and shoddy operating practices demolished the defences which aircrew and techies normally rely on to cope with occasional emergence of 'bad stuff'. All the "ops stuff" as an earlier poster put it is totally relevant - progressive erosion of safety margins created the holes through which this and three other recent avoidable RAFAT accidents could occur (I include the Cranwell gear-up landing).

In hindsight it's evident that the unit culture was rotten - witness the recent 'Reds to wed' business if any further dirty laundry from the preceding OC's tenure is required. If heads are to roll, they're to do with shocking supervision of a squadron that should have been under tight scrutiny given the history of display flying, elite units, three crashes and a fatality (too many coincidences here by far, I'm afraid). It sounds as if the AOC's interest in the programme was based solely on the risk of over-flying the hours (2-star PowerPoint management, anyone?) and beyond that it was "business as usual" in the club. Appalling.

[Chugalug2]

Easy Street:-
Airworthiness provision cannot alone deliver safe flying operations....and nobody here has suggested that it can, AFAIK, but we have seen the tragic results of the lack of it in thread after thread in this forum.

From the moment that seat was placed in that aircraft there existed a potential for an airworthiness related accident to happen and sure enough it did, with fatal consequences.

Now we have the curious situation that a report into that accident has been issued by the UK Military Airworthiness Authority, aka the MAA, aka the MOD, and you say that:-
the report does not make airworthiness failings its focusHow very unsurprising!


Self Regulation Doesn't Work and in Aviation it Kills!

[Justanopinion]

I am pleased that the covening authority recognised the professionalism of the panel in the inquiry process.

I wish to highlight that the conduct of this Inquiry has not only been challenging from a technical perspective, but also emotionally so for the panel members................their duties have necessarily brought them into direct contact with a proud and at times, perhaps understandably, defensive organisation..........The panel have conducted themselves wholly professionally and have striven for objectivity - I acknowledge their moral courage in doing so and thank them for it.

[1.3VStall]

I'm 100% with Chug and tuc on this.

Way back in 1988 the RAF Engineering Branch dined out ACM Sir Bill Richardson at RAF Abingdon. He was the last true Chief Engineer - CE(RAF) - and he was held in total admiration and respect by the whole Branch, as was evident by the mass turn out on the evening. On his watch Sir Bill had presided over a system that was fit for purpose.

Since then we have seen the insidious and continual erosion of the airworthiness chain, overseen by a succession of inadequate, unaccountable and unfocused VSOs (even the title CE disappeared) who now remain in self-supporting denial despite a series of well-publicised, airworthiness-related accidents.

It is relatively easy to bring to book an operator who has sharp pencilled flying stats. However, it is is much more difficult (and unpalatable to some) to call to account the actions of the VSOs whose actions have reduced the UK military airworthiness system to the sorry state that it is today.

So, Chug and tuc, continue with your campaign and I wish you success!

[Easy Street]

Chug - I don't think we'll have to wait too long for an SI report that will be a real acid test of the MAA's integrity and will provide plenty for the airworthiness campaign to get its teeth into (I speak of course of Tornado CWS). But I really feel that the flaws in the Mk10 seat design could not reasonably have been anticipated or spotted by MoD / DE&S - which is all the more evident since the seat was in service in halcyon pre-cuts days. No system is ever 100% safe or foolproof, which is why operators need training, experience and procedures to mitigate known and, to the extent practicable, unknown weaknesses in their kit. Two technical weaknesses snuck through the system at no obvious fault of DE&S, and erosion of the accepted operator safeguards allowed them to line up. Desperately unlucky, and far more attributable to the breakneck pace at which cockpit activity was conducted than any VSO meddling with airworthiness funding long after the Mk10 was in service.

I fully support your campaign and look forward to you taking MoD apart over Tornado CWS!

[Easy Street]

One other thing - it's the Military Aviation Authority so it can focus on whatever aspect of an accident it feels appropriate, not just airworthiness!

[tucumseh]

Easy Street

While I agree with the vast majority of what you say, I think you are too kind to DE&S. After all, they are just a rebrigaded DPA and DLO, and MoD(PE)/AMSO before, with the same people (or their acolytes) in charge.

The SI report has many recommendations pointing to abject failures on DE&S's part (and their predecessors). It doesn't spell them out or explain the background, but that is the way of SIs. But ANY civilian engineer in DE&S with more than 5 years service should know;
a. Backwards, the procedural Defence Standard that, if implemented, would have prevented these failures, and that,

b. It was canceled without replacement about 5 years ago.
Every MoD Technical Agency was issued with his/her own copy of both books, for permanent retention. Still got mine. It is THE bible. If you take the engineering recommendations of the SI, I can point you to the section in the Def Stan that covers it, and is mandated.

That is a top level system failure and any investigation should uncover this fact very quickly, especially as it was a major factor in Nimrod, Chinook, Sea King, Tornado, Hercules etc etc. It is the recurring nature of this failure that should disturb everyone.

Haddon-Cave rightly reported the failure was implementation. The MAA is concentrating on re-writing the regulations. The SI report is all about failure to implement perfectly good regulations. That indicates a system that is not fit for purpose.

I've deliberately avoided mentioning the aircrew and leaders of the Red Arrows. Many excellent posts above say it all.

[Distant Voice]

Bronx (#406)

I am afraid that AVM Jerry Connelly is 100% spot on. The airworthiness failures have been flagged up for action in numerous reports; Chinook, Nimrod, Hercules and H-C. They have all been ignored. This line of thinking is ignored by the SI Board and Coroner, probably because noone has been allowed to draw their attention to the evidence.

DV

[Halton Brat]

Is it possible to permanently install a small mirror to the aft face of the control column, such that the seat occupant would be able to view the correct installation of the pin, moving the column as required to optimise the viewing angle?

Obviously, consideration of full & free movement of the control column is the priority here.

HB

[BEagle]

HB, although I understand your suggestion, it would be a far from simple matter to modify the control column as you suggest. There would also be considerable risk of sunlight reflections causing distraction. When glued to a mate's wing, the last thing you would want would be a sudden flash in your peripheral vision from the lower cockpit area.

I only did 145 hrs on the Hawk 30+ years ago during a Valley refresher and at Chivenor, but I don't recall a single instance of a problem checking that the seat firing handle was correctly stowed and pinned.

I don't believe that there is a significant problem, provided that there is sufficient 'timeline' allowance for the pre-flight checks to be carried out diligently.

[vulcan558xh]

The deliberate falsification of continuation training, instrument flying and instrument approach records is a wholly different matter to mere forgetfulness.
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Words from Warren Buffett come to mind that give a great perspective when looking for new hires which states :
“ In looking for people to hire, you look for three qualities: integrity, intelligence, and energy. And if you don’t have the first, the other two will kill you. You think about it; it’s true. If you hire somebody without integrity, you really want them to be dumb and lazy.” Well said Mr. Buffett! The perception of the integrity of an organization depends on the pattern of actions of management, which are observed by the employees on a day to day basis. These patterns are consistent of management behaviors, personal values, beliefs, and actions that are thought to be acceptable within the organization’s guidelines, values, and principles.
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Flt Lt Cunningham died because of a failure of his seat to do what it was designed to do. The events leading to this tragic event have been investigated in detail and we all have a view in hindsight of how ths event could have been avoided. No doubt "Lessons will be learnt" as always and life carries on.

What has shocked the most is the realisation that lying and cheating was common place among the team and those in command turned a blind eye or possibly encouraged these actions. Personal integrity appeares to have counted for little in this group of aviators.

[airpolice]

Just a thought, how many flying hours would a Red get in a year?

How many times what a "normal" fast jet driver gets in a year is that?

[airpolice]

558, it seems that for the RAf to move on and improve, the incident needs to be considered, and dealt with, as three distinct things.

The seat firing.

The seat failing.

All of the dirt that was exposed by the inquiry into the first two events.

[goudie]

I once worked for an IT company where all managers were set performance targets. Some targets conflicted with each other. If you achieved one you had to let slip another one. Some targets were nigh on impossible to achieve in a busy and competitive market place. Promotion, salaries and even job security were based on these targets so people fiddled and cheated. However as long as a set of 'achieved' target figures were presented to the senior management, they didn't ask questions, as business was very good! The auditors were the ones to watch out for!
Could it be, that with the highly visible and at times, intensive workload of the RAFAT, priority was given to the tasks that were highly visible?
The deliberate falsification of continuation training, instrument flying and instrument approach records were neglected because it may have been nigh on impossible to achieve both these tasks and the displays, which of course, was their raison d'etre.
From my business experience it's an easy and pervasive culture to slip in to

[Distant Voice]

Is it possible to permanently install a small mirror to the aft face of the control column, such that the seat occupant would be able to view the correct installation of the pin, moving the column as required to optimise the viewing angle?

Use an inspection mirror on the A/F and B/F, or motor the seat to the correct (non Red Arrow) position.

By the way what does the the A/F and B/F documentation say for the tradesmen checking the ejection seat. Gets no mention in SI. Perhaps it is another piece of paperwork that has gone missing, or never updated.

DV

[tucumseh]

The deliberate falsification of continuation training, instrument flying and instrument approach records is a wholly different matter to mere forgetfulness.

I am loathe to condemn any aviator, and won't.

If you recall the Mull of Kintyre evidence, the Aldergrove detachment was criticised for poor paperwork practices. But the reason apathy set in was because VSOs had stopped funding e.g. fault investigations, and Engineering Authorities had been instructed not to seek investigations. In 1991 all such engineering decisions on airworthiness related faults were in the hands of very junior Supply Managers at Harrogate. (This evidence, and actual letters, were given in evidence to Lord Philip). The front line were criticised by the ZD576 BoI, but the underlying system failure was not even mentioned. Same as this current case.

While perhaps worse, I think one will find a similar underlying reason why the Red Arrows pilots thought they could falsify documents. After all, they must have known it is a specific offence under, for example, the Air Force Act. Someone condoned it.

If Court Martialed, their defence will be interesting. They don't need to look far for precedent....

Exhibit A - ACAS's false Chinook Release to Service in November 1993. Was he instructed to do this? We don't know, but Lord Philip confirmed the RTS was in every way a false representation of the facts. And there is no doubt his fellow VSOs knew what he did. After the crash, Wratten even wrote him a letter asking when the aircraft was due to be airworthy.

Exhibit B would be a series of four letters between 28.11.12 and 13.2.13; three from DE&S policy branch and one from the Head of the Civil Service. All four uphold previous rulings, by the RAF and PE/DPA that refusing to obey an order to make a false declaration is an offence, but issuing that order is not an offence. The December 1992 ruling by the RAF Chief Engineer's immediate subordinate was the subject of a 3.5 year investigation, which advised PUS the ruling was wrong. Yet, the policy remains extant.

If the Reds are reading this, and you find yourself in the dock, let me know because I'd love to see what happens when those policy rulings are read out in court. Then we'd maybe have a chance of seeing the real culprits answer for their actions. Also, have your representative call the Provost Marshal, as he has this evidence but declined to act upon it. I'll send him another copy. :E

[Chugalug2]

Easy street:-
One other thing - it's the Military Aviation Authority so it can focus on whatever aspect of an accident it feels appropriate, not just airworthiness! If that's aimed at me, Easy, I wasn't implying that it was called anything different. What I was trying to say is that UK Military Airworthiness Authority is vested in the MAA.


There would be no point in it being called the Military Airworthiness Authority for the simple reason that it doesn't do airworthiness, for the simple reason that it doesn't get airworthiness. If it did, it would cut itself adrift from the MOD and from the MAAIB and get to reinstating the enforcement of the perfectly good regulations that tuc speaks of, instead of wasting its time and effort in writing new 'workaround' ones.


It is a matter of great urgency that it be independent of the MOD and of the MAAIB, for only then can we expect it to take airworthiness seriously enough to carry out its principal function, ie to ensure that avoidable accidents are avoided. Ditto all the above with the MAAIB.


Self Regulation Doesn't Work and in Aviation it Kills!

[Short Lift Wet]

Tuc,

If the RAFAT pilots end up in the dock it sounds as if they would be totally bemused - they are probably amazing at seeing fault in formation flying but completely unable to identify right from wrong otherwise.

After all, they think a minute or so is enough to check their SE and change. They are alone in military aviation in thinking that rushing is good and checking is bad. They think they can wear what they want. They don't really see the need to check the F700. They don't think training records are a good idea. They are happy to lie about sim time, CFT, actual and approaches. Their head shed don't really understand how their engineers are trained. Flight safety meetings are someone else's issue, and FRCs are at best suggestions. A mid air and previous tragedy weren't enough to shake them from the very depths of poor behaviour. What gives you the impression that a CM will manage?

I fondly imagine they would go for blank looks or simply trot back to a 'you're not one of us - you wouldn't understand' defence.

I think we can divide this neatly. There are endemic air worthiness issues which allowed an ejection seat to malfunction once fired. However it fired, in large part, because it was used by a unit that was rotten to the core.

[Clockwork Mouse]

Wow!!
What experience have you had of the RAFAT that generated such a bitter and defamatory post? whatever it was has clearly traumatised you.

[switch_on_lofty]

Clockwork Mouse, have you read the SI, in particular the sections on culture, flight preparation etc? It is clearly written, evidenced and in my view damning. I can see why SLW has reached his conclusions, although they may be a tad OTT considering the tragic circumstances of this thread.
The SI uses a number of theories to explain why cultures like this can begin and perpetuate. Gouldie's post shows to highlight how people can fall into the trap of believing that everything is fine "our core output is IT/doing air shows etc. and that's going well so everything else must be fine".
The Reds are not the only unit to suffer from small unit syndromes such as these, look at the SI into the almost sinking of (now former) HMS Endurance on the same gov.uk website to see some very similar themes.

[Clockwork Mouse]

Yes, I have read it.
The section on culture etc is a disgrace. It describes a recent social psychology theory which has some, but not complete, acceptance among sociologists and, without any supporting evidence, states that it might be applicable to a close knit, elite unit like RAFAT and, if so, might have been a contributory factor. Theory dressed up as fact. And yes, I am a psychologist.
I would also not be surprised if you discover in due course that the allegations of misconduct in pilot training record keeping are on very shaky evidence and much more limited than the block smearing of the report implies.
RAFAT bashing in the intemperate terms expressed by SLW are disgraceful in my view. But then I am but a Pongo, albeit an educated and broad minded one.

[Inshala]

Enough please. What has not been exposed and probably never will be is the following:

1. The 'falsification of records' relates to two sorties. The first, when CT serials were entered into the auth sheets after each pilot flew a CT sortie. Doubt was cast by the SI over the amount of time the pilots had to fulfil these serials. No evidence was provided that this could not have been done in the time logged. The second was noticed in Flt Lt Cunninghams logbook, after the SI noticed he had entered a 40 minute sortie when the auth sheets showed 35. After an investigation, this issue was cleared.

2. The SI knowingly printed in their report an incorrect 'timeline'. They were informed of the errors in their timeline by the Team Leader but chose to ignore the actual timeline used. The actual timeline gives an additional 4 minutes from step to walk from that printed in the report (12 mins), which allows the pilots plenty of time to complete ALL checks, F700 etc. Also, the SI references the RAFAT timeline against other Hawk users which is misleading in the context of RAFAT ops. A RAFAT brief takes between 5-15 minutes, which includes all domestic aspects of the sortie, an emergency, loser plan and out-brief. Extensive use of SOPs helps greatly in this regard. The SI NEVER observed a RAFAT brief-walk-chek-in-taxy-take-off so has no context. Some of you question integrity...

3. The sim issue is irrelevant as the amount of time flown in the sim counts towards nothing. The pilots were completing their emergency sims in approximately 35-40 mins, more than enough time to complete the required emergencies and this is backed up by the testimonies of the sim instructors. Claiming one hour in your logbook for the sim might not be correct, but it is irrelevant to any currencies as the sim counts for nothing except a 'tick' that an emergency sim has been conducted. Also, currencies were questioned in the context of the number of sims conducted per year. This relates to a technicality in the Reds Display Directives that states that 6 sims should be completed annually. This was only in the Directives as the 22 Gp sim currency is 2 months. However, the Team are allowed a 1 month extension (3 months total) at the discretion of the DDH (Cmdt CFS) which they use every year when they go to Cyprus. So every year, they do 5 (and a half) but are always 'current'. This 'error' in the Directives has been amended with the removal of the '6 per year' line. Incidentally, all non-22 Gp Hawk operators (100 Sqn and the Navy have 3 month currencies for emergency sims). This issue was investigated and cleared.

4. The ONLY difference the Reds had to aircraft checks was the following: the FRCs say to close the canopy, remove pins and then start the GTS. These checks had been modified decades before to the following: Start the GTS, close the canopy (while the GTS is starting) and then remove pins. Engine is then ready to start as it takes 20 secs for the GTS to come online. While this may have been incorrect iaw the FRCs, this procedure had never been questioned by annual FSV, CFS Trappers (the Reds do them annually, not every 2 years as stated by Orders) or any external visitors, of which their are dozens every year. The reason the Team did this was to warn all engineers that the canopies were about to be closed and that they should 'hide' under the aircraft in case of inadvertent MDC initiation. With up to 11 aircraft starting at once and lots of engineers close to the aircraft, this was considered best practice but has since been changed.

5. The SI claimed that pilots were logging IF when they (the SI) believed the weather conditions did not allow it. They went through met records for one day during the 2011 display season when all pilots claimed IF. Met records showed BKN cloud up to 9000ft on this day and the SI did not believe this was enough to fly on instruments. BKN can be 5-7 octas of cloud and they based this accusation on this. This issue was investigated and cleared.

6. As a result of the conduct of this SI, the SI process itself is being looked at by the MAA (new DG) with a view to modification; specifically the right of reply by the Service. While some good work was undoubtedly done by elements of this SI, especially regarding the over-tightening issue and the forensic level examination that looked at how the handle MAY have been moved into an unsafe condition, many of the 'other factors' were opinion-based with little solid evidence to back them up. Many of them were thoroughly investigated and cleared, yet they remain in the report.

7. While there was no mandated Air Safety Management Plan completed by the Cmdt at the time, it had been started. When Eggman was killed, the Cmdt made the decision to spend his time with the Team and look them in the eye every day to make sure they were good to go, instead of sitting in his office writing this management plan. He ultimately pulled the plug on RAFAT flying in early September (2 weeks before the end of the 2011 season) over concerns with one of the pilots who was not coping well. If he had not, there may well have been an accident. In my eyes, that is good supervision.

There will always be those of you who will want to believe every aspect of this SI and how gash the Reds might be, but I would urge caution before you jump to conclusions. They are every bit as professional as they were when they were on the frontline and take great pride in what they do. Please consider what I have taken the time to write before you have hung the Team as guilty.

[Bob Viking]

How dare you bring reasoned debate and first hand knowledge to the table. You should be well aware by now that supposition and hearsay are far better tools for this forum!
I've thought long and hard before commenting on this thread since I know all of the guys involved and it wouldn't be a stretch for them to work out who I am. The fact is that I have flown with them many times before and I would fly with any one of them again tomorrow.
I've been around long enough to know how FJ units and SIs work. Whilst some aspects of the report make for bad reading it does not paint them in the light that I myself have witnessed first hand. I would struggle to find a more professional, focused and competent bunch. There are those on here who will love to knock them and believe what they hear about them being a bunch of arrogant prima donnas but unless you know them personally or have flown with them you really do not know what you're talking about.
Trust me when I say there's a reason they are held in such high regard by the public. They are bloody good at what they do and have suffered from a period in their history that would make many grown men weep.
Please remember when you publicly denounce them (from the safety of your internet anonymity) that they live a very different life to your average FJ pilot and that brings with it good and bad. Having my name dragged through the mud on here wouldn't make me very happy and I'm sure you'd all feel the same.
I probably won't post on this thread again since I don't want to enter into any heated debates on the subject but just felt I should add what support I can offer from a standpoint of someone who actually knows the guys and has flown with them.
BV

[BEagle]

Inshala, if there was such a discrepancy between the SI and your narrative, surely an official complaint would have been raised before it was released to genpub access?

Moreover, the SI stated that more than one pilot was flying without a valid IR. I found that strange as I was under the impression that military IR validity is maintained by test, not experience - but perhaps things have changed over the years.

The SI paints a bleak picture of RAFAT culture and practices; if that picture is (hopefully) as incorrect as you allege, then 'an MoD official' needs to come out and confirm your views. Otherwise it will simply go unchallenged and people will be none the wiser.

[airpolice]

Inshala, I'm sure there are people who will be convinced by your allegations that everything is fine and the SI is a stitch up.

For me, the telling part is the way in which you simply dismiss the bits that you don't want to claim are untrue.

Claiming one hour in your logbook for the sim might not be correct

This relates to a technicality in the Reds Display Directives

While this may have been incorrect iaw the FRCs,

this was considered best practice but has since been changed.


They are every bit as professional as they were when they were on the frontline

In that last bit, are you suggesting that other service pilots are signing false reports because "it's all good" even though the paperwork is wrong?

Why was it so difficult for someone to say, "we only need 40 minutes in the sim, not an hour" and get the paperwork changed?

[wiggy]

Why was it so difficult for someone to say, "we only need 40 minutes in the sim, not an hour" and get the paperwork changed?

Agreed :D :D

The same applies for any other instances of "pencil whipping" that may have gone on. If the recurrent training/ continuation training requirement does not fit in with the RAFAT's bespoke operation, or is not achievable given the demands placed on the Reds then somebody needs to "man up", to use the current vernacular, and get the rules reassessed/rewritten.

Wiggy,

Former Sqn "stats" officer and chaser of the SD98 rate, .....and if asked I will tell you I never sharp pencilled anything....:*

[Evalu8ter]

"The fudging of hours for IR recency or CT hours might have no bearing on this particular tragedy, but what kind of culture is it exposing?"

Perhaps it showcases an issue familiar to many on the Front Line; namely that VSOs need a plethora of currency 'requirements' and computer based tracking tools to copper-bottom themselves against comeback whilst providing unrealistic targets and insufficient resource to achieve the task. Why? They've continued to perpetuate the myth that you can cut resource and increase output...because the previous incumbents of their jobs managed it why can't they? Final proof perhaps that there are more 'be-ers' than 'do-ers' at the top of the RAF.....

Oh for a system that bred supervisors and VSOs that understood the issues and constraints, rather than hide behind a computer spreadsheet and say 'all was well on my watch...'.

[Chugalug2]

I cannot vouch for the conduct of RAFAT as a unit, because I have no personal knowledge of it. What I would say is that the criticism made of it in this SI bears a familiar ring from previous SIs/BOIs. What did the Mull pilots have for breakfast? Did they have any at all? In that case it acted as a diversion from the elephant in the room, that the aircraft was grossly unairworthy and was flying under an illegal RTS.


Mull showed clearly that lying, stealing, and cheating existed at the very top of the RAF High Command. Illegal orders were issued by Air Rank Officers who are still not condemned, only those who refused to obey them are. If such an example is set by those in High Command, it is only a matter of time before such practice appears at a unit near you!


RAFAT may well need attention in that regard, again I do not know, again I take what the MOD says, through its MAA subsidiary, with a pinch of salt. What does need attention is the RAF High Command. By protecting their predecessors they continue to compromise Air Safety. While the UK Military Airworthiness Authority remains in house, vested in the MAA (see what I did there Easy Street?) that will continue to be the case. While the MAAIB remains in house and within the MAA, it will continue to be the case.


The MAA has been judge and jury in its own regard. This aircraft was unairworthy. That is the elephant in the room!


Self Regulation Doesn't Work and in Aviation it Kills!

[Just This Once...]

I have to be very careful here, but to keep things on course some facts may reassure some people that due process has been followed:

- Any irregularity that could, at first sight, appear to be a serious service offence has been thoroughly investigated without fear or favour.

- The investigation was not confined to the members of the team at the time.

- The investigation did look at the actions of the senior leadership over an extended timeline.

- The investigation did look at those who had left the Service.

- The decision to charge or to take disciplinary action would have been made at the correct level and did include the Service Prosecuting Authority.

- The matter was referred to Dominic Grieve.

- The SI provided grounds for an investigation, nothing more. Everyone is innocent until proven guilty. The correct people have made the decisions and we must trust their decisions. We must not infer any guilt on any party just by the mere existence of an investigation.

-The thoroughness of the investigation (however painful) should give us confidence, not erode it.

The SI did what it was directed to do; nothing more and nothing less. It was rightly commended by the DG MAA.

[Chugalug2]

JTO:-
The SI did what it was directed to do; nothing more and nothing less. It was rightly commended by the DG MAA.Which makes my point succinctly. It should not be up to the DG MAA to commend an investigation by the MAAIB into an airworthiness related accident, but to jolly well get on and carry out its recommendations. One is reminded of the BA737 tragedy at Manchester, when training had to be greatly modified and much extra kit installed in all aircraft on the UK register above a certain size. All that was recommended by the independent AAIB and enforced by the independent CAA on all UK AOC holders.


Am I alone in finding your quote disturbing, in the light of previous BoIs featured in this Forum? They did what they were directed to do. That was the problem.

[Inshala]

All valid points of view, I am merely trying to add some context to each allegation.

BEagle, this was considered, but ultimately it could have delayed the SI and the Inquest and the Team just wanted to put this behind them finally.

While there have been some issues in the past (highlighted by the SI), I know from experience that the Reds are not the only Sqn to have had them. What I would also like to add is that over the past 2 and a half years, the whole Team has changed. They have a new Leader, Wing Commander, pilots, engineers and support staff and every inch of RAFAT business has been extensively looked at and modified if deemed necessary. They have had to endure these years of constant and over-bearing scrutiny, accusations and never-ending inspections and investigations but got on with the job with stoicism and moral courage. They have delivered 2 excellent display seasons, a major foreign tour and non-stop engagement. Ultimately it was the Team that got the Team through it all; now they want to move on and enjoy at least one season of display flying. Of note, they are averaging 6 external inspections per year and have done so since 2011. This would affect any Sqn but the result has been many excellent reports, improvements across the entire Team and probably the most 'compliant' Sqn ever.

If any of you would like to visit Scampton and see for yourself, I would be happy to try and arrange something as I do have one or 2 contacts there.

Enough from me I think and I wish you all well.

[Just This Once...]

JTO:
Am I alone in finding your quote disturbing, in the light of previous BoIs featured in this Forum? They did what they were directed to do. That was the problem.

Hi Chug,

I was not offering an opinion, just a fact. The ToRs for the SI are available online and are considerably more wide-ranging than pre-MAA precisely to address the concerns you and others have raised.

They do give the panel the ability to question the actions of the MAA and report directly to SofS. They also give the panel (deliberately mixed service with independent oversight) the ability to question the actions of VSOs and hold them to account. You may be in a better to position to judge if this final part is being exercised with the release of another unrelated SI in the coming months.

I know your view on the independence of the MilAAIB but I would genuinely appreciate your view on the scope of the SI ToRs and offer up any potential improvements as they may help to drive a change.

Regards.

[airpolice]

I know from experience that the Reds are not the only Sqn to have had them.

That's my point. How could the findings of previous boards have gone unactioned by Scampton?

More importantly, is everyone else now getting "all of their **** in one sock" to ensure that this is the last time that we read about such cultural indifference to regulations?

[dervish]

JTO

I have a problem with at least three of your facts. They may be true in isolation but the SI did not look beyond and assess common failures. It therefore failed in one important duty.

[Just This Once...]

dervish, that is indeed unfortunate and suggests we still do not have this right. Do you feel able to elaborate in any way?

[dervish]

JTO

Unless I'm wrong a SI, like the BoIs before, has at its disposal a contributory factor called organization failure, or fault? It should say it has definitely eliminated the possibility, not imply it isn't there. The report ignores previous failures that haven't been corrected. I agree with chug. The MAA comments come across as backslapping when what we want them to do is fix the problem. I don't think they even understand it.

[Chugalug2]

Hope this image doesn't distort the page, and apologies for not cropping it (tried but failed!). I assume this is the change in TOR that you refer to JTO. I don't wish to appear churlish, but fear I will. No amount of such workarounds will alter the fact that the MAAIB is part of the MAA which is part of the MOD. Independence is no more divisible than is pregnancy. You are or you aren't. You aren't (independent that is ;-).




http://i184.photobucket.com/albums/x199/chugalug2/HawkSITOR_zps251c19d6.png

[Just This Once...]

dervish, I understand your point and the SI process does not specifically look to directly apportion blame or fault. Clearly by demonstration of the facts, or by informed opinion, it can and should highlight areas of weakness. In this case it did trigger additional investigations and reviews in to what has gone on.

This report did highlight reoccurring issues common to previous SIs; given the short span of time between some of them it is understandable that this should be the case. As for your inference that we have yet to correct all the issues sewn in the past, well in my opinion this is true. Indeed, in some regard I am not convinced we have intellectually accepted that all of the issues actually exist. Again, this is my personal opinion and others are free to differ.

One of the other changes introduced with the MilAAIB and MAA is that the MAA is accountable for ensuring the the corrective actions are tracked and implemented. The MAA is empowered to take direct action against accountable persons - they have done this recently without the catalyst of an actual accident. Over time the cumulative actions of the MAA will feature more and more in reports, especially if corrective action is not actually carried out and just pushed down the road. This is why I support the policy where the SI can investigate MAA actions and report to the SoS via PUS.

[Just This Once...]

Chug, that is the change and no, you do not come across as churlish. We (the MoD) have done great harm to ourselves and catalysed the mistrust. I do not claim that all the monsters have gone away but my professional opinion is that there is not a monster under every bed; to claim otherwise only provides a means of obfuscation for those who try to convince us that all is perfect.

Compared to my direct and evidence-based concerns the MilAAIB is one of the true success stories. I do not expect you to take my word for it as history will be a brutal auditor of its actions.

Anyway, enough from me as there are other opinions out there that probably matter more than mine.

[dervish]

JTO

Thank you for that excellent reply.


the MAA is accountable for ensuring the the corrective actions are tracked and implemented.

The report doesn't comment on why the same failures have happened again. Seems the MAA hasn't bothered meetings its own rules. Perhaps the requirement is taken so literally they don't have to look at common denominators? Either way I don't see the point.

[Vendee]

Having worked under the CAA and the MAA, it seems to me that the MAA is just the poacher wearing the gamekeepers clothes. It needs to be independent of the MOD.

[Distant Voice]

I note that the SI team states, in summary, that they identified four Aggravating factors, but list only three, and 13 Observations, but list only 12. Either we have a team that can not count, or listed items have been removed by someone, on review.

By the way, none of the 17 Contributing factors caused the death of Flt. Lt. Cunningham; the cause was the failure of the seat to operate correctly. It's like saying that the act of AAR caused the loss of Nimrod XV230, rather than the faulty fuel couplings and hot air pipes.

Come on MAA, you have to do better than this.

DV

[Genstabler]

The credibility of the report is compromised by a lot more than that I'm afraid.

[Two's in]

By the way, none of the 17 Contributing factors caused the death of Flt. Lt. Cunningham; the cause was the failure of the seat to operate correctly.

The SI says the cause was "an inadvertent ejection following the application of a force to the SFH..."

The definition of contributory factors in the SI appears consistent with the findings.

[Flying Lawyer]

The definition of contributory factors in the SI appears consistent with the findings.

The SI defined Contributory Factors as 'factors that directly or indirectly made the accident more likely.'

Even allowing for that quite wide definition, the basis for describing some of the factors as contributory is mere speculation without sufficient foundation in evidence.

There is an important difference between speculation and drawing a fair and reasonable inference from proved facts.
And also between drawing a fair and reasonable inference from proved facts and attempting to fit the evidence to a theory.

FL

[Fox3WheresMyBanana]

Is it not the case that the cause of the accident was the inadvertent operation of the seat, and the cause of the fatality was the failure of the seat to operate correctly?
The SI was primarily considering the cause of the accident.

FL - agreed. e.g. point h. Self-medication. The text identifies it as a possible contributory factor, but the summary states that it was a contributory factor

[Flying Lawyer]

The SI was primarily considering the cause of the accident.Yes, but the Inquiry Panel's Terms of Reference were far wider than that.

See Paragraph 2 and Annex A here: Convening Order (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/277773/XX177Part_1_2_convening_order.pdf)


FL

[Easy Street]

F3,

The complication is that the fatality WAS the accident. The aircraft was only Cat 1. I was trying to get my head around the contributory/cause/aggravating thing a few pages back, but no-one really cleared it up. The board went for inadvertant ejection = cause, chute failure = aggravating factor. Having mulled it over I disagree with them because if the chute had worked, there would have been no "accident" in the strict sense of "major injury/Cat 4". So I think I would have gone for inadvertent ejection = contributory factor, chute failure = cause.

[longer ron]

ES - trouble is I think one could argue that point either way !
Without the ejection - nothing happened !

[Chugalug2]

lr:-
Without the ejection - nothing happened !But if it had been a commanded ejection then the seat would still have malfunctioned and still resulted in a fatal accident. Easy Street is right, Flt Lt Cunningham died in an Airworthiness Related Accident because his seat parachute could not deploy. This was a compromised SI, like the others concerning Airworthiness Related Fatal Military Air Accidents that litter this Forum.


This has to stop. The MOD's finger prints are all over this SI, just as they are all over the disgraceful delaying of publication of the Report until after the Coroner's Inquest. Theirs was the only version of events readily available to the family and to the court. The MAAIB is dependent on the MAA (who were responsible for ensuring the airworthiness, or lack of it, of XX179), and the MAA is dependent on the MOD. Until that incestuous trio are entirely separated from each other the scandal of avoidable military airworthiness related air accidents will continue with its awful cost in blood and treasure.

[overstress]

Inshala, would take issue with your The ONLY difference the Reds had to aircraft checks was the following: the FRCs say to close the canopy, remove pins and then start the GTS.

From the report, it seems they didn't carry out their control checks in the recommended way either, as reference to the 1994 Valley accident to XX164 which claimed the life of one of my colleagues. (I was involved in a minor way with the recommendations after that BOI - I was tasked with re-writing the draft aircrew manual section for the new procedure). It's a small point, but brings up the fact that seemingly unrelated unofficial changes to SOPs can turn round and bite you eventually.

I'm fairly sure that when I was taught the workings of the seat back in 1986 our course was shown the 'position 2' of the handle and the fact that it was possible to place the pin in an unsafe way. I always remembered the teaching and i used to stick my head in the cockpit to check the pin was home correctly before standing on the seat. Did this corporate knowledge somehow get lost over the years?

[Flying Lawyer]

Easy I was trying to get my head around the contributory/cause/aggravating thing a few pages back, but no-one really cleared it up.

The SI adopted the following terminology -

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: Factors that were none of the above, but could cause, contribute to or aggravate a future accident.
Observations: Factors that were not relevant to the accident but worthy of consideration to promote better working practices.

It is a pity that factors which in the opinion of the Panel did not lead directly to the accident, and did not directly or indirectly make the accident more likely, have attracted the most unpleasant and emotive comments in this thread. SOP for some PPRuNe contributors.

Transparency in such investigations is obviously desirable but it's a great pity that, in some instances, the integrity of individuals has been publicly impugned on the basis of what some might regard as at best flimsy evidence.


FL

[Fox3WheresMyBanana]

Apologies - I'd missed the low level of damage to the Hawk. I would therefore agree that the cause was the failure of the scissor shackle to operate correctly. The cause of which would appear to be miscommunication of some kind between MB & MoD

[Bronx]

Chugalug2 But if it had been a commanded ejection then the seat would still have malfunctioned and still resulted in a fatal accident.
It would still have been an accident even if the seat had not malfunctioned and Flt Lt Cunningham had landed safely.
I wonder if you are confusing the cause of the accident with what caused it to become a fatal accident?


the disgraceful delaying of publication of the Report until after the Coroner's Inquest. Theirs was the only version of events readily available to the family and to the court.
Since the family and the coroner had copies of the report, what's the problem?
The coroner heard evidence from some witnesses and would have seen witness statements made by others. He could also require anyone else to attend if he thought they might be able to help his inquiry.
Whose 'version of events' do you say should have been available to the coroner and wasn't? :confused:

The MOD allowed the Coroner - who is independent - to complete his investigation and publish his findings before publishing the MAA report which you claim is biased anyway.
Why is that disgraceful?

[Genstabler]

Overstress

It's a small point, but brings up the fact that seemingly unrelated unofficial changes to SOPs can turn round and bite you eventually.

Please explain what you are implying in this statement.

In my, albeit narrow, experience details of FRCs can be amended in the course of 20 years. Indeed you seem to have been involved in such an amendment yourself 20 years ago.

[Easy Street]

Bronx

If the chute had opened then there would have been no accident and hence no SI. Longstanding mil occurrence categorisation holds that an "accident" involves major injury (broadly, broken limb or worse) or Cat 4 damage to aircraft. If Sean had walked away then this would have been merely an "incident" and subject to nothing more than a unit inquiry, which would not be released by default (although FOI would probably see it released if someone asked the right question).

[tucumseh]

It is a pity that factors which in the opinion of the Panel did not lead directly to the accident, and did not directly or indirectly make the accident more likely, have attracted the most unpleasant and emotive comments in this thread. SOP for some PPRuNe contributors.

Well said. And MoD/MAA, who routinely do this to detract from the real issues. As stated earlier, MoD has a long history of deflecting blame onto juniors. One must always ask who their actions protect. In the last 20-odd years the same names crop up regularly.



I would therefore agree that the cause was the failure of the scissor shackle to operate correctly. The cause of which would appear to be miscommunication of some kind between MB & MoD


But inbetween there was some poor engineering practice. On such an assembly the test has got to be freedom of movement, not torque or visible thread. However, I won't be too critical because there was no mention of what action the maintainers took, and whether or not it they were ignored - which is all too common.

But what the SI failed to mention was the systemic failures noted many times over a 20 year period. And, withheld from both SI and Coroner was the fact there is evidence of excellent communication coming from Martin Baker about the seat, increasing the chances the breakdown was within MoD (where it was practice NOT to communicate with Design Authorities because it was deemed a waste of money).


Just a couple of points that, if made available to the SI or Coroner, would have changed their direction significantly.

[Distant Voice]

Beagle, I fully agree with your post #479. The inadvertant (speculation) firing of the seat was an incident, caused by the apparent inabilty to fit the seat pan safety pin correctly. An incident that should have been prevented by whoever carried out the B/F on 4th November (No one mentioned in the SI?). To this incident the SI assigns 17 factors, but only 3 (or 4) to the real cause.

Cause of death; severe internal injuries caused by impact with the ground after falling 300 ft

Cause of accident; failure of chute to deploy

Cause of accident Sequence; inadvertent operation of firing handle.

DV

CORRECTION

B/F should read A/F

[Chugalug2]

Bronx:-
Since the family and the coroner had copies of the report, what's the problem?
The coroner heard evidence from some witnesses and would have seen witness statements made by others. He could also require anyone else to attend if he thought they might be able to help his inquiry.
Whose 'version of events' do you say should have been available to the coroner and wasn't? http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/confused.gif
The MOD allowed the Coroner - who is independent - to complete his investigation and publish his findings before publishing the MAA report which you claim is biased anyway.
Why is that disgraceful?Let's dot the i's and cross the t's here. In previous fatal accidents the BoI was published ahead of a coroner's inquest. This enabled the family and the coroner to get input from other than the MOD alone. It was then often the family that became the focus of a campaign to right an injustice, insist that aircraft receive the protection that their brother's hadn't, or to simply reveal MOD lies for what they were. The mandarins have obviously decided that this is unacceptable from their point of view, and so have limited publication to non aviation professionals only, ie the family, its lawyers, and the coroner.


As usual this SI points the finger at the first person on the scene of the accident, whereas the genesis of this accident began in 1988 when RAF VSOs began deliberately to destroy the system that had assured UK Military Airworthiness Provision. That system remains broken and will go on being broken until the MAA faces up to cause and effect, and breaks away from the MOD so that it is free to publish and be damned. Ditto all that, especially in regard to this accident, with the MAAIB.


Rather than stemming the canker of unairworthiness that infects UK Military Aviation, the MAA is presiding over the spread of it from fleet to fleet. The MAA is part of the problem and not the cure. It needs to take urgent action as above, or the 63 deaths noted in this forum will simply go on growing inexorably.

[The Nip]

I am just confused by the use of the 'accident' word. It seems it CAN be used to take away responsibility for what can be preventable.

Surely there is someone somewhere who is responsible for system failures. It seems in all walks of life, people want the pay and prestige of having responsibility, but when push comes to shove it is never their fault, always an accident.

Sorry.

[Distant Voice]

The mandarins have obviously decided that this is unacceptable from their point of view, and so have limited publication to non aviation professionals only, ie the family, its lawyers, and the coroner.


This is in violation of Chapter 7 of JSP 832. Which basically says that in high profile cases the families should be informed just prior to a ministeral brief and this is followed by posting the report on the internet. This is how the Nimrod case was dealt with.

DV

[longer ron]

An incident that should have been prevented by whoever carried out the B/F on 4th November (No one mentioned in the SI?)

The pin is checked by everybody who enters/works in cockpit,it is only 'fitted' by the pilot unless on deeper maintenance than first line !

[longer ron]

One could argue either way about the cause of the accident,but it is different to the cause of death !
Whilst the failure of the chute to open was the cause of death,this would not have happened if the seat had not fired in the first place - so it would be fair to say that the seat firing was the cause !

There still seems to be resistance to accepting the circumstances causing the seat to fire...
I cannot comment on the wider accusations about VSO's etc but I can say that the technical investigation of this tragic accident was very in depth and of an extremely high standard...it was always going to be a difficult one !!

[Chugalug2]

longer ron,


Here is the MAA's own Master Glossary. You will see that there was no accident until Flt Lt Cunningham was killed, which as you say was caused by his chute failing to open. The SI itself stated that the aircraft only received Cat1 damage, as has already been pointed out. It would have had to receive Cat4 or 5 damage for it to have been the subject of an accident :-


http://www.maa.mod.uk/linkedfiles/regulation/maa02.pdf


This is not some arcane argument about angels and heads of pins. Rather it is proof, if any were needed, that SIs are still subject to outside influences and cannot be relied upon to do their job. Their job should be to determine accident causes in order to prevent future occurrences. Rather it seems it is to go on protecting VSO backsides at the cost of more junior ones.

[Distant Voice]

The pin is checked by everybody who enters/works in cockpit,it is only 'fitted' by the pilot unless on deeper maintenance than first line

Yes, I appreciate that, and I would not go anywhere near a seat without checking the position of the pin(s) very carefully. Having said that I would have thought that part of the A/F servicing for an armourer would be to ensure that the seat pin was correctly located. If the aircraft was going into the hanger then pins should be in the safe for servicing position, which includes the firing sear. It is so basic.

If it doesn't say that, what does it say?

DV

NOTE
My post #489 should have said A/F not B/F

[longer ron]

Chug

I am not bothered either way...as I said previously - one could argue either way about and it makes no practical difference anyway !
This accident was highly unusual in that the aircraft was only slightly damaged just yards from the operators hangar.
This alone makes the cause/occurrence unusual but I would not read anything into that particular wording unless one wants to be pedantic !

[longer ron]

DV
I understand what you are saying,I was just saying that it is a shared responsibility,safety check wise the last person who enters the cockpit has the responsibility to check the pin and in this case that would not have been the tradesman !
I have seen quite a few people on here who have never missed checks/made mistakes...to err is to be human - yes it is a basic check but with a Hawk front seat one has to be aware that viewed from above it is a subtle defect,one has to move ones head down and fwd to see the handle/pin relationship clearly,which I am sure we all do now.

rgds LR

[Bronx]

Chugalug2 Let's dot the i's and cross the t's here. You haven't done that, you;ve just repeated your broad brush conspiracy theories.

In previous fatal accidents the BoI was published ahead of a coroner's inquest. This enabled the family and the coroner to get input from other than the MOD alone.
The SI report was given to the family and the coroner ahead of the coroner's inquest. This enabled the family and the coroner to get input from other than the MOD alone.
The Coroner did that.
The family had a QC advising them and he questioned witnesses on their behalf.
The family could have asked the coroner to hear input from other witnesses including experts if they'd wanted to.

From the Telegraph report of the inquest:The team leader at the time, Sqd Ldr Jim Turner, said he was frustrated by a lack of support and a shortage of around 20 engineers.
He said: “We were telling them repeatedly we needed more personnel and more aircraft. The sense that I had in the short time I was boss was that we needed more stuff. We needed more manpower. We needed a little bit more.”
He said when he took over the job he was surprised to see some of the engineers were “very young and very inexperienced”.

You still haven't answered my question - Whose 'version of events' (your expression) do you say should have been available to the coroner and wasn't?

[Distant Voice]

LR. Did any ground tradesman sign for the A/F, and did that A/F, iaw bla bla bla, require a seat check?

DV

[SirPeterHardingsLovechild]

DV
Did any ground tradesman sign for the A/F, and did that A/F, iaw bla bla bla, require a seat check?



The SI did not go into such detail, but I can guarantee that tradesmen will have signed for checking the seat pins.


However, Flt Lt Cunningham himself signed in the aircraft after the 4th Nov flight and this rather trumps everything. Unless of course the Reds have some arrangement which wouldn't surprise me.

[goudie]

surprised to see some of the engineers were “very young and very inexperienced”.
If these engineers were on their first tour then there has been a change in policy.
I'm pretty certain that at one time, engineers had to have completed at least one tour elsewhere and been 'above average', before being considered for the RAFAT.
Same applied for postings to 'The Queen's Flight'.

[Chugalug2]

Bronx, the discussion on this thread alone shows what can become apparent once access to a published SI report is possible by professionals (and I count all those who have posted here in that manner, lest you think I am claiming some unique insight). The suggestion that showing this SI alone to non-professionals prompts them to ask informed questions about it is disingenuous. They are told that the cause of this accident was the (inadvertent) initiation of the firing sequence, and why should they not accept that? Yet I am not alone on this thread in claiming that to be plain wrong, and that the cause was the failure of the scissor shackle to open, allowing main chute deployment. That is just one example of the version of events differing to that offered to the family and the coroner.


If you don't know what questions to ask then you don't ask them. If you don't know what version of events has been published then you cannot dispute them. Those are the i's and t's that were not dotted and crossed at the inquest. Why? Because publication was withheld for that very reason.


Previous Coroners have heavily criticised the MOD for the state of its aircraft. By delaying general publication of the SI that criticism was curtailed. We cannot rely on the MAAIB to determine the cause of airworthiness related military air accidents, and have had to rely on an 800 year old institution to point out our airworthiness shortcomings. Now that window has been effectively closed by the MOD. In doing so it reveals its disinterest in maintaining Air Safety, and I encourage others to ask themselves why should that be?