Martin Baker to be prosecuted over death of Flt Lt. Sean Cunningham

[Chugalug2]

Thank you Stuff and gr4techie for your assurances that both air and ground crew are properly instructed in Live and Safe for Parking procedures (thanks stuff, I'll try to remember not to use "armed" and "disarmed" again) and to rigidly conform with them accordingly. I had little doubt it was otherwise, hence my concern at m0nkfish's post.

It will be interesting what effects the submission of reports called for by the court have, as posted by LFH. Could it be that certain revelations made here have already had some effect? Will there be yet even further rescheduling? This case has very important implications for every UK military aviator and for the MAA. Put 17/05/2017 in your diaries now!

[tucumseh]

Martin Baker pleaded Not Guilty in court today. Trial set for January 2018. No mention of MoD's admission of serious offences on its part.

[Chugalug2]

Great news tuc! Thanks for the info. So at long last someone is prepared to stand up to the MOD! Why HSE ever chose to take MBA to court rather than the MOD is still puzzling, but no doubt there are those better informed who can cast some light into these murky corners.

What never changes it seems is the snail like pace with which such matters of life and death take these days. There was no safety case, rendering both seat and aircraft unairworthy. How many other systems and aircraft are in service similarly waiting to pounce and start yet another tragic Airworthiness Related Fatal Air Accident thread on this forum?

[salad-dodger]

...but no doubt there are those better informed...
almost certainly.

S-D

[dervish]

S-D

An uncalled for snipe, especially as MoD themselves admit no safety case. No one has said MB are innocent, but MoD have admitted guilt but escaped prosecution.

[EAP86]

S-D

An uncalled for snipe, especially as MoD themselves admit no safety case. No one has said MB are innocent, but MoD have admitted guilt but escaped prosecution.

While individuals employed by MOD can be prosecuted under the HASAWA for failing to perform their prescribed duties, the MOD cannot. At the most, the MOD could only expect a Crown Censure (by which the Health and Safety Executive records there would be sufficient evidence to secure a H&S conviction against the MOD).

EAP

[dervish]

Thanks EAP86. Understand. I was thinking of the previous decision by the CPS not to prosecute MoD. IIRC there was a formal announcement, mentioned earlier in the thread.

[Chugalug2]

EAP86:-
At the most, the MOD could only expect a Crown Censure (by which the Health and Safety Executive records there would be sufficient evidence to secure a H&S conviction against the MOD).


Then let us hope that is exactly what happens. Personally I would rate Crown Censure of the MOD as equivalent to a conviction, given that the latter would merely mean the PBTP would end up picking up the tab anyway. As to:-

While individuals employed by MOD can be prosecuted under the HASAWA for failing to perform their prescribed duties

We can only hope that the apparent exclusion of those of 2* and above from any prosecution under Military Law does not extend to the HASAWA.

[Just This Once...]

Yep, for the MoD and other government bodies the maximum sanction is either a Crown Sensure or a Regulation 28 (previously a Rule 43). Of course, those that claimed an adequate safety case when one did not exist can be sentenced for up to 2 years with or without a fine - even if no incident arose due to the failing. The mere act of failing to check is enough for a prosecution (Armed Forces Act 2009).

Of course, nobody has ever been prosecuted and the non-existent ejection seat safety case was relied upon and quoted in a coroner's court previously. Hopefully the court will remember that Sean Cunningham's death was not the first that questioned the Mk10 safety management and airworthiness.

Air Marshal Leeson used his comments on the Mike Harland accident report to champion the safety record of Martin Baker, whilst rejecting some of the report's recommendations. As to how Air Marshal Leeson could oversee and comment on the airworthiness of the Mk10 ejection seat without reference to the safety case just hangs in the air...

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/27130/ZA554_boi_tornado_rpt.pdf

[tucumseh]

I was thinking of the previous decision by the CPS not to prosecute MoD.

This decision only addressed the seat servicing. The CPS, as ever, evaded its responsibility to address corporate level failings. (Followers of the Nimrod XV230 case may recall it and Thames Valley Police lied to families, saying no-one would come forward with evidence, omitting to say they were sitting on witness statements).

JTO - good post. If I might just add a reminder that it is MoD's responsibility to ensure a valid Safety Case. It is inconceivable that Martin Baker don't hold the necessary evidence, but likely that they were simply not under contract to produce the mandated Safety Case Reports - again, similar to Nimrod XV230. More than likely, given public admissions by the former IPTL.

[Just This Once...]

From what I understand the prosecution of MB is appropriate and follows quite a few issues at that company. Somehow a halo-effect took hold around MB, its designs and its ability to honestly investigate, learn and communicate issues with the seats. Worryingly they seem to have addressed design issues with some customers whilst leaving others in the dark.

[tucumseh]

I wonder if anyone stumped up to attend the lecture about XX177 by MoD's Hawk Type Airworthiness Authority (at the time of the accident) last month at the University of Chester? He was a witness at the Inquest. Did he mention why there was no safety case report to be found? Or the impact this had on the validity of the aircraft safety case?

As an aside - and I'm no legal person - why are Martin-Baker prohibited from speaking to potential witnesses under contempt of court rules, while MoD employees are allowed to give public lectures when the case is sub judice? Even if permitted, a strange thing to do given it admitted serious offences.

[roving]

As an aside - and I'm no legal person - why are Martin-Baker prohibited from speaking to potential witnesses under contempt of court rules, while MoD employees are allowed to give public lectures when the case is sub judice? Even if permitted, a strange thing to do given it admitted serious offences.

Crown employees
11 Although the Crown is bound by the general duties of the Act it cannot be prosecuted nor can it be served with improvement or prohibition notices (HSW Act s.48). (Though administrative sanctions, including Crown censure and Crown notices are available.) This immunity from formal enforcement applies to central government departments, and Crown bodies such as HM Prison Service, as well as to other organisations in specific circumstances, e.g. the Environment Agency when it is undertaking specific duties for the Minister. If you have any doubt about the status of an apparently 'crown' body then contact the Public Services Sector (Defence, Fire and Police Unit) for advice.

Prosecuting individuals - OC 130/08 (http://www.hse.gov.uk/foi/internalops/ocs/100-199/130_8.htm)

[tucumseh]

No lawyers here who can answer my question? Is a witness at the inquest, who will be a potential witness at the court case (as Type Airworthiness Authority, presumably he had some say in the decision not to have a valid ejection seat or Hawk safety case) permitted to give lectures on the subject? Is this a form of contempt?

[Lordflasheart]

Last I heard, May 2017 Sky News - https://news.sky.com/story/ejector-seat-manufacturer-to-go-on-trial-over-red-arrows-pilots-death-10881378

- was that the case would open at Lincoln Crown Court on 22nd Jan 2018 - now less than two months away.

Judge John Pini QC said the trial, which is likely to last four to five weeks, will begin on 22 January at the same court.

Perhaps he was practicing his speech in case he is called ? Unless they've changed their plea ??

LFH

.....................

[Chugalug2]

LFH:-

Perhaps he was practicing his speech in case he is called ?

If he is called it won't be to give a speech but to give evidence and face cross examination, while on oath to tell the whole truth and nothing but the truth.

[Never Fretter]

And hasn't the then SEngO been doing promotional presentations on the accident on behalf of a certain training company who it is said were actually working with the Reds on "compliance" issues BEFORE the ejection??

[dragartist]

Tuc, looking at this fellas credentials I wonder how he was considered by his superiors as SQEP?
I have no doubt that they are having difficulty filling positions.
Another point: he would have had to get his presentation cleared prior to delivery to the RAeS. When I gave a presentation I had to have a synopsis approved prior to completion. Then all my slides had to be approved. They needed a great deal of notice and only just made it, having had to chase them a few times. All the rules were set out in a DIN.
Still the rules keep changing. I have been gone six years. I guess these days folks are allowed to log on to xhamster at ABW without fear of dismissal.

[tucumseh]

Dragartist

I'm not sure there even is a definition for SQEP. I know there is for 'inexperience'; at least in my field. One has to have (successfully) managed (not just worked on) at least 125 projects to be even considered for promotion to PPTO/UG7/B2. I know this because my MP once raised this during the Nimrod case (as Haddon-Cave noted the safety manager was not SQEP). MoD declined to say how many staff satisfied this criteria. I have an opinion. And it is not very high.

[Wander00]

For the dim or ignorant, "SQEP"?

[PPRuNeUser0211]

Wander- suitably qualified experienced person.

As for project management within defence procurement being SQEP - please don't make me laugh any more!

[Wander00]

aah - I had made a guess close to that but thought it must be really complicated so dismissed my attempt! Thanks

[tucumseh]

As for project management within defence procurement being SQEP - please don't make me laugh any more!

A commonly held view, which ignores that the majority of projects are delivered to time, cost and performance - or better - with effortless competence. There is a reason why MoD won't release Post Project Evaluation reports - because the reasons for the high profile failures were predictable, predicted, notified and ignored. Very often the primary cause is failure of management oversight. How many at that level meet the SQEP criteria?

One could take this further and ask what the background was of those who notified and were ignored. One would find they are what most here would look for in a SQEP. This applies to both projects and the deaths Chug refers to. While I disagree with the above 125 successful projects criteria, someone must have considered it reasonable and attainable.

[dragartist]

I think most of us would agree pba, I think it a little unfair to throw people in to the deep end. I was led into things gently with small projects with suitable mentors. Although I hated it at the time, being moved out of aircraft Office into the equipment office, I realised afterwards that it was part of the grooming process to come back to head the aircraft office. Don’t believe I could list 125 projects to my name but I did receive recognition for a good number.

[view from above]

@Never Fretter....the point you make is? A spot of training solves what is likely to be ingrained issues that go back many years? Most of these issues are not training problems...most drivers are trained yet choose to use their mobiles!

[Dusty_B]

I was at the Chester lecture. Alan O'Connor was at pains to report only on publicly available information, rather than give opinion or new information. It was an excellent presentation, humble particularly due to his own role within the system, and cemented for me my decision not to return to flying (or indeed anything else) with the RAF Air Cadets.

Whilst MB have their part to play in the death of SC, they will end up taking the public flack for an event (or series of events) that lead up to the shackle not releasing that had very little to do with them. It'll be a useful smokescreen for hiding why he ended up at 100' AGL in the first place.

[tucumseh]

Thank you Dusty B. I think the point is that the 'publicly available' information (i.e. MoD's version) is full of holes. Did he mention the serious offences admitted in the SI report? Primarily, a series of false declarations about and within the Aircraft Document Set which the Type Airworthiness Authority would be party to, or certainly be expected to spot at a casual glance.

We all know that at a certain level people just sign papers thrust under their noses. But if asked to put my name to a legally binding document saying I have personally assured myself there is a valid safety case, I'd expect said safety case report to be attached. Indeed, a certified copy in the filing cabinet closest to hand. One's 2 Star has to assess the top ten risks every month. Here, 'can't find safety case report for ejection seat' would be #1, so what on earth was said at these reviews? That 2 Star has a lot to answer for.

I'd be interested to know what part M-B is thought to have played. There was a suggestion that, in 1990, they didn't disseminate a technical bulletin; but whoever wrote that hadn't bothered to read MoD's own regulations. Assuming the company don't roll over to preserve relations, I suspect MoD will be asked some pretty embarrassing questions.

Pity the court case was delayed. It wouldn't have lasted 5 minutes had Judge Haddon-Cave sat, as originally planned. No safety case? Directed verdict and early lunch. Anything else and he'd have looked foolish.

[airsound]

...court case...wouldn't have lasted 5 minutes had Judge Haddon-Cave sat, as originally planned Interesting point, tuc.

I'm sure you're not suggesting another conspiracy theory, whereby the learned judge's absence from the trial had anything to do with the fiendishly cunning MoD....?

Or are you? (oooer missus)

airsound

[PDR1]

A commonly held view

Vox populi, vox veritatis

The nation has spoken, but perhaps it's the 99% who give the rest a bad name...

:E

PDR

[tucumseh]

airsound

I couldn't possibly comment!



PDR1

Ditto!!

[Lordflasheart]

Is this prosecution still due to commence on Monday 22nd ?

The Court lists - Lincoln / 19-01-2018 (http://causelist.org/lincoln/) - usually seem to be updated the night before at the earliest and there's nothing recent in the media.

LFH

............

[tucumseh]

LFH

Scheduled for 22nd, but for example I am aware the defence team actively tracked down former MoD witnesses who were in post in 1990 (date of one alleged offence), but have since failed to interview all but one. This may indicate the HSE has finally read the evidence (as of October last, it clearly hadn't) and realised it was MoD who admitted imprisonable offences. Or perhaps Haddon-Cave, who was due to hear it on the original date, had a word in an effort to (a) avoid wasting public money, and (b) avoid embarrassing the CPS (an impossible task!), HSE and MoD. No Safety Case, No Fly. End of.

[airsound]

Have just called Lincoln Crown Court Listings. They confirm the case is due to start on Monday 22nd.

Earlier information suggested it could last 4-5 weeks.

airsound

[Distant Voice]

No Safety Case, No Fly. End of.

No gas shackle modification. Problems with the scissor shackle were known about in 2002, at the latest.

DV

[tucumseh]

Thanks airsound. Wonder what the defence line will be, if they're apparently not using the witnesses they sought? I can see it's risky simply pointing at someone else; but when that someone else has actually admitted wrongdoing, things look distinctly odd. Perhaps an unwillingness to upset MoD. Day 1, witness 1 'Please read aloud CAS's admission that there was no safety case. Then tell me who made false record that it existed'.

[Wander00]

Well on current CPS/police form, at what late stage will it become apparent either there is no case to answer or evidence has been withheld from the defence.....only asking.....

[Mortmeister]

It's not left to the crew, the procedure is in the FRCs and is standard across the fleet.



Pin stowage on all types I've flown are highly visible from the ground so the ground crew will know at a distance if the seat pins are in or not.

As a side note, the seat is never referred to as being armed or disarmed. To do so would be to suggest that when 'disarmed' it's entirely safe. It is not, the explosives remain in place. The seat would only be talked about as being 'live', 'safe for parking' or 'safe for servicing'. I'm sure the armourers have further distinctions beyond 'safe for servicing' but that would involve serious specialist knowledge of the seat in question.

Correct.
I'm an ex-armourer (25 years), with 6 years on Hawk at 2 TWU (1988-94).

Safe for Maintenance:
All AAES pins fitted

Safe for Parking:
MDC Internal Handle, MDC Firing Unit and Seat Pan Firing Pins all fitted. Ejection Gun, Rocket Initiator and Manual Separation Pins in the cockpit stowage.

It was common for Hawks to taxi onto the pan with MDC Int. Handle and Seat Pan pins refitted by the crew (stowage visibly empty). Aircrew would then refit the MDC Firing Unit Pin on exiting the aircraft.
I flew about 40 hours as 'back seat' engineer and was always told to refit as above on taxi in once clear of the runway and I always flew with a QFI/QWI, never students.
I always took this to be that in the event of having to evacuate the aircraft once off the runway, we would be climbing out as opposed to ejecting.

Only once did I ever see a student get out and leave the entire seat live. He was so elated at passing his last trip. When our senior QWI found out, he had the guy almost in tears as he tore him apart! Probably one of the most heinous crimes a 'stude' could commit.

Regards
Mortmeister

[k3k3]

Martin Baker have pleaded guilty to the charges laid against them.

Red Arrows death firm admits failings - BBC News (http://www.bbc.co.uk/news/uk-42773834)

[hoss183]

Martin Baker have pleaded guilty to the charges laid against them.

Red Arrows death firm admits failings - BBC News (http://www.bbc.co.uk/news/uk-42773834)

Wow.
Knowing what we know, that begs all kinds of questions. Are MB taking one on the chin to protect their best customer?

[PDR1]

Wow.
Knowing what we know, that begs all kinds of questions.

Including "do you actually know what you know?" and "Do they know things that you don't?"...

PDR

[tucumseh]

Perhaps wiser to wait to see if the specifics of the charge(s) are revealed. Initially, it was a catch-all charge. In October, it was narrowed down a bit, but still very vague. As PDR1 implies, there has got to be something else, because (as DV mentioned a few days ago) there is a 2002 QinetiQ report that makes a nonsense of the accusations made at the Inquest.

[airsound]

Danny Savage, BBC correspondent, will report in 1300 news.

airsound

[ciderman]

They have pleaded guilty. Great shame when you consider the number of lives that have been saved in the past. I feel sorry for all concerned.

[roving]

Perhaps wiser to wait to see if the specifics of the charge(s) are revealed. Initially, it was a catch-all charge. In October, it was narrowed down a bit, but still very vague. As PDR1 implies, there has got to be something else, because (as DV mentioned a few days ago) there is a 2002 QinetiQ report that makes a nonsense of the accusations made at the Inquest.


The guilty plea today avoided the trial. Sentence has been adjourned until 12 February.

Immediately prior to sentence the basis and particulars of the charge and the basis of the plea, together with any mitigation, will be explained in open court.

[airsound]

Here's Martin-Baker's statement:Martin-Baker Aircraft Company Limited
Press statement for Monday 22nd January 2018


Firstly and most importantly we express our deepest condolences to the family and friends of Flight Lieutenant Sean Cunningham.

Today, Martin-Baker Aircraft Company entered a guilty plea to a single breach of Section 3 (1) of the Health and Safety at Work Act 1974. This plea was entered following detailed and lengthy discussions with the Health and Safety Executive which have considerably narrowed the issues from when its investigation first started. It should be noted that this was an isolated failure relating to the tightening of a nut during maintenance procedures conducted by RAF Aerobatic Team (RAFAT) mechanics.

Martin-Baker Aircraft Company has designed and manufactured ejection seats for 73 years and in that time these ejection seats have been flown by 92 air forces, with over 17,000 seats currently in use. Our ejection seats have saved the lives of 1,050 British Royal Air Force and Navy aircrew, with a further 6,009 aircrew lives saved around the world.

Martin-Baker’s priority has and will always be the safety of the aircrew who sit on the Company's seats. We appreciate that the Health and Safety Executive, during this process, has acknowledged this dedication and track record of saving lives.

A further and more detailed press statement will be released at the conclusion of these proceedings.


airsound

[tucumseh]

Thanks roving and airsound. So, a single breach; a change from the two charges in October; and it would seem it relates to the over-tightening of the nut (by MoD, in accordance with an illegal instruction issued by the MoD). That's probably why this was an 'isolated failure', because previous procedures were safe.

[Just This Once...]

Glad to see MB brought to book. I have witnessed too many issues and dismissive attitudes to have any sympathy with this company. For far too long they have dined on the goodwill provided by the lives saved rather than an open, honest and questioning safety culture that can admit to design errors.

The RAF are but one customer of this company and the attempt to imply that this fatality was due to RAFAT mechanics (today's press release) suggests they have a long way to go to engage with their customers.

For those who wish to lay the blame at the UK MoD may wish to reconcile as to how similar issues arose with other nations and the inexplicable difference in safety information shared with multiple international customers. The only common factor is Martin Baker and whilst they have pleaded guilty they just could not help themselves to having one last jab at the very last chap who tightened this poorly designed shackle.

[tucumseh]

JTO

While it is possible Martin-Baker erred in some way, the RAF's offences are admitted.

The Routine Technical Instruction the maintainer was working to was illegal. An RTI or UTI is only permitted if the Design Authorities (M-B and BAeS) are NOT involved. On a safety critical escape system, they must be. The crucial issue is that an RTI/UTI does not ensure a safety case update. This is why they are not Special Instructions (Technical), and aren't even mentioned in the authoritative Def Stan. Had the correct route been taken (an SI) then the lack of a safety case would have been flagged. Oversight was lacking, as it had been removed as a savings at the expense of safety. Plainly, no one with the remotest understanding of the regulations scrutinised this entire process - which had nothing to do with M-B.

Regardless of whether the 1990 bulletin was issued to MoD (and the only office it was required to be sent to ceased to exist in 1993, so how can one prove it either way?), MoD has released the 2002 report in which the warning about the possibility of the shackle jamming is crystal clear. This renders the alleged offence entirely academic, as MoD admits that it knew nine years before the accident.

The maintainer cut new thread on a bolt. The nut and bolt were therefore immediately scrap, but were not replaced. We don't know why, as his evidence has not been released. My own experience - you feel it.

The Service Inquiry made much of the 1.5 threads issue, ignoring a contradiction in MoD training that says one thread. Had it been one thread, the parachute would have deployed. I can't speak for the RAF, but an RN maintainer would follow NAMMS and his trade training - one thread. Also, out of interest, the FAA says one.

There's a lot more to this, and I'm afraid I must disagree that the only common factor is Martin-Baker. One crucial common factor between this and other cases is that 56 of the 60 recommendations in the SI report can be summarised - do what the regulations tell you to do. NONE of them are Martin-Baker failures.

[oldmansquipper]

Well said Tuc....

[Chugalug2]

Good post, tuc. The pigeons are now coming home to roost. We may expect more harrumphing from the apologists in the meantime. The cover up appears to consist more and more of filigree lace these days.

[WHBM]

From the BBC :

Coroner Stuart Fisher described the seats' safety mechanism as "entirely useless"

http://www.bbc.co.uk/news/uk-42773834
I wonder how much this buffoon understands about ejector seats, or mechanical engineering in general, and how it can be that it took 20 years (at least) before this issue came to light. And how many successful deployments came in that time.

[tucumseh]

WHBM

Agreed. Importantly, because the SI report was not released until after the Inquest, the court only heard MoD's highly edited version of events. His words were unwise, and he should have at least added balance by pointing out MoD's offences, but he was serially misled. It looks like this issue of quality of design is what has been dropped by the HSE after discussions 'narrowed the issues' (i.e. being allowed to present independent evidence for the first time).

But I'd still have liked to have heard the head of Tech Pubs tear into the claim MB didn't send out the bulletin in 1990. He's been waiting since 27 October for the solicitors to take evidence. Having tracked him down, but gone no further, this was the indication something was going on.

[Distant Voice]

this was the indication something was going on.

For sure something is going on. The charges were watered down in order to prevent MoD being brought into the dock and quizzed on things such as safety cases.

DV

[NutLoose]

American stuff always has been 1 thread in safety, but in the RAF I was taught it was 1 1/2 theads, and it was hard changing over in my mind to the lesser standard when I had too.

[Just This Once...]

Good post, tuc. The pigeons are now coming home to roost. We may expect more harrumphing from the apologists in the meantime. The cover up appears to consist more and more of filigree lace these days.

Wow, I’ve become an apologist now.

This series of seats had numerous design issues. Some of these were communicated to some customers, but others were not.

I give no slack to the MoD when justified, MB deserve the same. Airworthiness directives and notifications are not something that can be lost due to MoD reorganisation. They are formally issued and tracked by the company with regulator oversight. The reason MB didn’t produce a copy was down to the fact it never existed then or any subsequent year. Worryingly, when evidence of damage was noted by MB during numerous post-accident ejection seat inspections they still didn’t warn the customers or issue an airworthiness note or directive. One must now question the use of MB to support accident investigations as they are neither honest or independent.

Feel free to throw as many stones at the MoD as you like as they have presented many rich targets. But in this case the Inquest, Coroner and prosecutors didn’t find a neatly bound and airworthy design, supported by carefully honed documents communicated to all with a robust feedback loop with a single guilty-looking end user ignoring all concerns and design changes. They found a company with a cavalier attitude with flawed internal safety management and a seat design the coroner called ‘utterly useless’. That company has now admitted its guilt at the eleventh hour, so why should we consider them innocent?

[PDR1]

...and a seat design the coroner called ‘utterly useless’.

Did we get to learn about the Coroner's engineering and/or flying qualifications, or was he/she just another excitable heckler?

PDR

[tucumseh]

This series of seats had numerous design issues. Some of these were communicated to some customers, but others were not.The trouble with ejection seats is one cannot demonstrate the required System Integration Readiness Level as quickly as most other parts of an aircraft design; not least because one hopes that in-use experience is rare. The design evolution is not a normal iterative process. And one iteration does not necessarily lead directly to the next.

This means the reporting a feedback loop of the Safety Management System must be robustly implemented. MoD more or less stopped this in June 1993. It had already issued instructions to curtail Fault Investigations and Technical Publication amendments in 1991-2. That is a significant timeframe here.

M-B stand accused of not sending a single Camera Ready Copy of a Technical Bulletin to the Seat Engineering Authority. In 1990, that was small office, probably one man and his dog. But at least it was a single point of contact. But with successive re-organisations, such centralised functions were shut down (reiterated by Haddon-Cave). So, which new stove-pipe did the 1990 seat EA bring his single CRC to? Probably not Hawk. Tornado perhaps? If only because it was the single biggest user. The claim by the SI was that MoD could not find the bulletin. Did they track down the 1990 EA and ask him? At the Inquest this somehow morphed into M-B did not provide it, but it seems this was more a misunderstanding and clumsy wording than an accusation. In fact, M-B's solicitors were so unconcerned they paid little heed to this aspect - which I don't think served their client very well.

Place your self in the seat EA's shoes. He gets a bulletin saying 'don't over-tighten the nut'. He perhaps speaks to CSDE, who laugh at him. 'Teaching armourers to suck eggs, no way we're sponsoring a tech pubs amendment, ATP would laugh at us. And the money's been chopped anyway'. So, the seat EA does not need to take the next step, informing the aircraft EA. RAFHS at Boscombe don't get a sniff. It's marked 'no further action', and stuck in an anonymous file.

Then ask when we stopped employing Technical Authors for the Topic 4s. Around 500 posts chopped, and it was contracted out - at precisely this time. Allied to that, we heard of poorly trained MoD maintainers. When those changes (cuts) were being made, the Training Needs Analysis should have been updated, to recognise the new, lower levels of expertise. In turn, the Pubs Authority (ATP) would say 'Pubs need to be updated to reflect the more detailed instructions needed for non-specialists who are now maintaining seats'. It wasn't just M-B who had to find a new way of conveying technical information to a dumbed-down MoD. The 'trainers of the trainers' had this precise problem in 1992-3 when seeking to work out how to have Chinook FADEC maintained. And the Director of Flight Safety let rip at the Chief Engineer and ACAS over it:
‘There is a gap in the present orders and procedures concerning the amendment of Air Publications. The problem lies with the question of what the tradesmen do in the meantime. Do they to work to and sign for an activity which is known to be wrong, or do they work outside the content of the maintenance document and thus be hostage to fortune should a problem occur?’

None of this has anything to do with Martin-Baker.


Airworthiness directives and notifications are not something that can be lost due to MoD reorganisation.Yes they are. When D/MAP registry closed down, following the announcement that HQ Mods Committees were being disbanded, thousands of files were never seen again. This was right in the middle of a 5-year 'freeze', when only the most critical projects were allowed to proceed. (In November 1994 I took over the top priority Support Helicopter programme, which had been endorsed in January 1990, but absolutely no progress had been made due to this freeze. As soon as the freeze was lifted, it was under contract in 48 hours. The first thing was a 4-phase risk reduction exercise to stabilize the airworthiness baseline, as it had lapsed in that time). Now, did this happen on seats? Probably. And it was nothing to do with M-B.

[Top West 50]

Remind me someone please, what was the cause of the accident?

[Distant Voice]

Remind me someone please, what was the cause of the accident?

The failure in 2000, by MoD, to have the scissor shackle replaced by the gas operated type, when they knew there was a problem.

DV

[PDR1]

Remind me someone please, what was the cause of the accident?

A technician over-tightened a nut.

PDR

[roving]

There is speculation here that the Red Arrows will in due course switch from the Hawk to the T-6C.

New aircraft for Red Arrows ? what are the options? | Combat Aircraft (http://www.combataircraft.net/2016/11/02/new-aircraft-for-red-arrows-what-are-the-options/)

cIwEG7opxtg

[SirPeterHardingsLovechild]

Remind me someone please, what was the cause of the accident?
The seat went off


SPHLC

[dook]

Well, I'm glad mine did !

[dragartist]

Top West, you ask a serious question.
Root cause?
The sequence of events:
The seat pan handle was operated - no one knows how or why. Speculation that the safety pin was not properly engaged and a strap had been passed through the yellow and black loop as young Cunningham moved about to settle into his seat and conduct his checks.
The seat fired.
The parachute failed to deploy. The cause being a bolt had been overtightened by an RAF technician. The bolt was quite critical. It should have not pinched the legs of the shackle together allowing it to swivel. The bolt was tightened such to show at least one and a half threads protruding from the nut. It had been tightened so tight to achieve this that it had cut a thread into the bolt. Poor design in that it was critical and should perhaps have been made fool proof. (A shoulder bolt or spacer tube to ensure the arms of the shackle were not pinched together.)
A simple check to ensure the shackle rotated about the bolt should probably have been wise. As this was essential to parachute deployment.
MB knew of the issue and had told other operators but apparently could find no evidence of having told their most “intelligent” customer.

Avoidable ? Yes. By design, by having appropriate training in place, by having appropriate documentation in place for maintenance, perhaps explaining the consequences of overtightening the bolt and knowledge of operation of the parachute deployment mechanism.

Oh and there being a Safety Case in place. The safety case would support the reasoned argument that the system posed no hazards to those involved in the maintenance or operation of the equipment. It would normally begin that the Designer is competent to design that type of equipment. It has been independently tested to ensure it meets the requirements specification. It has been maintained by competent people in line with a set of documented procedures. All to sub components are manufactured and sourced appropriately. Any hazards and incidents that come to light during use are properly investigated and addressed with lessons learned being promulgated.
So if it was known that overtightenng the bolt would prevent the parachute deploying that fact would be made known to the operators.

[Basil]

(A shoulder bolt or spacer tube to ensure the arms of the shackle were not pinched together.)
Yes, that's what I thought when I skimmed through the report - well, thought of spacer.
(Bas - ex marine eng)

[Flight_Idle]

Just a simple 'Feeler gauge' check for enough gap to ensure freedom of movement, if the bolts the wrong size then change it. Just don't clamp things together because the instructions tell you to.

How simple is it to have a properly engineered 'Gap' by feeler gauge, not all this 'Torque loading a bolt' so it's in 'Safety?' Just 'winding it up until the thread, or thread & a half shows through & clamping parts together as a result.

As I said much earlier, pilots used to 'Rackle the shackle in my day, to ensure that the shackle was really free.

[tucumseh]

A simple check to ensure the shackle rotated about the bolt should probably have been wise. As this was essential to parachute deployment.
MB knew of the issue and had told other operators but apparently could find no evidence of having told their most “intelligent” customer.Very recently (days, and too late), a report came to light showing MoD knew of various issues in 1999. This was concealed/withheld from Service Inquiry, Coroner, CPS, HSE and Police. The penny probably dropped that one MoD office had inadvertently released evidence that another sought to conceal, so the associated reports giving finer detail have not been released. (This has happened before, and is what sunk MoD on Mull of Kintyre). FoI requests are now rejected.

It is known that even if the shackle was free to move by hand, it could occasionally jam when under load. The design worked to the original aircrew weight spec, but not when it was changed to take account of heavier (male) and lighter (female) crew. This resulted in a modification to one seat variant, but not that fitted to Hawk. The question is why that mod was not adopted in Hawk. It is not as simple as a design flaw. It is more a case of an adequate design becoming less so when the spec is changed. This is routine, every day stuff to EAs and TAs in MoD; and industry.

This does not exonerate M-B over the claim not to have sent information to MoD in 1990 (demonstrably they informed BAeS, and it becomes a case of who was responsible then for initiating aircraft tech pubs amendments), but it does prove conclusively that MoD was wrong to claim it did not know in 2011. Legal authorities were misled by omission. Perjury is a possibility.

Why did M-B not use this report as evidence that MoD knew? We know the answer. Their solicitor's stated strategy of 'not upsetting MoD'. In my opinion, this makes all concerned complicit in future accidents that share this root cause (systemic airworthiness failings). We've been here before, too often.

[Top West 50]

Top West, you ask a serious question.
Root cause?
The sequence of events:
The seat pan handle was operated - no one knows how or why. Speculation that the safety pin was not properly engaged and a strap had been passed through the yellow and black loop as young Cunningham moved about to settle into his seat and conduct his checks.
The seat fired.
The parachute failed to deploy. The cause being a bolt had been overtightened by an RAF technician. The bolt was quite critical. It should have not pinched the legs of the shackle together allowing it to swivel. The bolt was tightened such to show at least one and a half threads protruding from the nut. It had been tightened so tight to achieve this that it had cut a thread into the bolt. Poor design in that it was critical and should perhaps have been made fool proof. (A shoulder bolt or spacer tube to ensure the arms of the shackle were not pinched together.)
A simple check to ensure the shackle rotated about the bolt should probably have been wise. As this was essential to parachute deployment.
MB knew of the issue and had told other operators but apparently could find no evidence of having told their most “intelligent” customer.

Avoidable ? Yes. By design, by having appropriate training in place, by having appropriate documentation in place for maintenance, perhaps explaining the consequences of overtightening the bolt and knowledge of operation of the parachute deployment mechanism.

Oh and there being a Safety Case in place. The safety case would support the reasoned argument that the system posed no hazards to those involved in the maintenance or operation of the equipment. It would normally begin that the Designer is competent to design that type of equipment. It has been independently tested to ensure it meets the requirements specification. It has been maintained by competent people in line with a set of documented procedures. All to sub components are manufactured and sourced appropriately. Any hazards and incidents that come to light during use are properly investigated and addressed with lessons learned being promulgated.
So if it was known that overtightenng the bolt would prevent the parachute deploying that fact would be made known to the operators.

Thank you. I found, through harrowing experience in one case and arguing in a political minefield in another, that defining the concise cause of the accident is the most demanding element of the inquiry. It's all very sad but it seems that the seat fired and everything else that happened only made matters worse.

On a personal note, I am exceptionally sad about the whole affair. I am the 664th of many thousands who now owe their lives to Martin Baker and I remember, as yesterday, the expression on the face of the Armourer who had serviced my seat as he presented me with the face blind handle as a souvenir.

[BEagle]

Having previously been trained on the Gnat and Hunter, when I returned to Valley for a refresher course on the Hawk, I was taught ALWAYS to check visually that the seat firing handle was fully down when inserting the safety pin and that the seat and MDC pins shouldn't be re-inserted until the aircraft was stationary with the engine shut down on chocks - "It's a zero-zero bang seat and you might need it as a last resort on the ground".

But I read that people are re-inserting pins as part of the after landing checks - why? Particularly an inexperienced passenger fumbling about. I can't see how a pilot can visually check that the pin has been correctly inserted if he/she is looking where the aircraft is going whilst taxying.

Although the SOP I was taught might have prevented the seat firing handle being pulled inadvertently, the over-tightened scissor shackle would still have proved fatal for a zero-zero ejection with no time to use the manual separation procedure.

[Bob Viking]

We covered this several pages ago. Rightly or wrongly procedures have changed over the years.

Saying that “it was much better in my day and I would never have made that mistake” are fruitless.

What I can say is that after Sean’s untimely death it is far less likely to happen to anyone else.

Can we put it to bed now?!

BV

[Fitter2]

What I can say is that after Sean’s untimely death it is far less likely to happen to anyone else.
I fear that what has been learned is that VSOs can hide their wilful and fatal misconduct, with the collusion of all concerned. I would dearly like to be wrong.

[Just This Once...]

I think we need to be confident that there isn't other latent issues hiding in the MB design and safety management.

Years ago a friend was logging his first proper seat time; after contemplating the rather violent change of scenery he started wondering when the parachute would make its appearance. He even had the presence of mind to remember he had a high level barostat fitted to the seat so the chute should have made a relatively quick appearance. When he tried to move his hand to the manual separation release he found the the sleeves of his LSJ were bound so tightly between his legs and so much material had been stretched by the force of the restraints (with the restraint fabric pulled through to the metal clips) there was no way he could move his hand over his thigh, let alone across his kneepad to operate the handle. He then spent time trying to work his way free of the Houdini straight jacket.

The chute did deployed before he got to the manual handle. MB's response to this issue was initially dismissive of an issue before deciding that the seat eventually worked so why should he moan.

Quite a few of us revisited the seat rig to contemplate what would happen when the restraint cords were pulled beyond the stitching (not possible on the training rig) and contemplated how much LSJ material would be pulled tight around the shoulders by the power of the arm restraints. Those of us with knowledge of the accident opted for a shorter LSJ sleeve length but outside of this circle the issue was treated with derision.

In the years since the arm restraint design has spread across multiple types and judging by the number of long LSJ sleeves I see one hopes that the issue has been resolved rather than forgotten.

Before this accident my sleeve length looked like this; I do not know if Typhoon mitigates the issue in a different way or if the issue has carried over:

http://i.dailymail.co.uk/i/pix/2013/06/05/article-2336526-1A2A9FB5000005DC-881_964x638.jpg

[Nige321]

If anyone needs their blood boiling, Jeremy Vine is covering this shortly on BBC Radio 2...

[tucumseh]

Can we put it to bed now?!

With the greatest respect, MoD/MAA constantly putting to bed accidents with the same root cause is what has caused recurrence and even more deaths. As I said before, 56/60 recommendations to implement mandated policy. 17 main factors, all MoD's liability. Three years before this accident there was a report concerning poor practice when fitting fasteners on Nimrod. Nimrod cancelled, report put to one side, as if it could only be a Nimrod problem, not (e.g.) one of general training, supervision and culture. Then, the XX177 SI rips into - training, supervision and culture.

[BEagle]

Bob Viking, can you please tell us WHY zero-zero seat pins (MDC too?) are replaced on the move these days?

Surely it would be better to do so only when stationary and before unstrapping?

[Riskman]

MB are quoted in today's Times "This was an isolated failure relating to the tightening of a nut during maintenance procedures conducted by RAF Aerobatic Team mechanics."
Is that a 'Yeah but it's still the RAF's fault' kind of comment?
Going back to page 1 of this thread, did 'some liney', 6 years ago, find their career come to an abrupt halt or have the RAF had to wait, without prejudice, for the HSE case to conclude before initiating any internal action?

[dragartist]

Hi JTO,
I do know that the RAFCAM integration team at Henlow did used to put a great deal of effort into the things you describe. Use of various crash test instrumented dummies and test rigs to simulate g etc. They also carry out detailed forensic examination of AEA that has been subject to actual use in events. Their top man has given a number of lectures to the RAeS on the subject. I understand that most recently their efforts have been focused on fire retardant gear and also body armour.
Not sure what will become when they move from Henlow. I would have thought the sensible thing to do was to merge with the QinetiQ gang at Farnborough. However there was always a willy waving contest between the two organisations which at one time, Pre privatisation of Q2 were more joined up.

[tucumseh]

dragartist/JTO

I fully agree. The 2002 QQ report, which informed MoD of the shackle problem (again), is a model example of a joint effort by M-B, BAeS, QQ and MoD. The vast majority in these organisations do a superb job.

But it is this report which renders the claim M-B didn't provide a bulletin a complete red herring. Had the SI seen it, they would have had to caveat their report 'the 1990 bulletin can't be found, but we got shed loads of subsequent notifications and did nothing'. The 'quality of design charge' was dropped by the HSE (who reported that?), which makes the Coroner look foolish (not reported either). But it looks like M-B took a hit on the administrative oversight charge just to get it out of the way, not realising MoD had withheld evidence that revealed MoD's greater offences.

Riskman - Yes, because it was!

[Basil]

If anyone needs their blood boiling, Jeremy Vine is covering this shortly on BBC Radio 2...
Thanks for the headsup.
Actually, wasn't as bad as I expected.
He'd John Nichol on for a user comment.

[roving]

dragartist/JTO

not realising MoD had withheld evidence that revealed MoD's greater offences.



I think I posted about this point once before. HMG cannot be prosecuted for alleged offences of the HSE, because the law does not apply to the Crown.

Ergo although MOD may have commited sins, it has not committed any offences.

Crown Immunity from Criminal Liability
Action in the criminal courts is taken 'on behalf of the Crown'. Statute law is approved by the Crown (Royal Assent).

It would, it is said, be strange for the Crown to prosecute itself and this is the basis for the Crown being 'immune' from prosecution for criminal liability.

The Crown is not, however, 'immune' from the requirements of health and safety legislation generally. All of these duties are placed on the Crown just as on any other employer. The only difference is what action can be taken under criminal law if the Crown fails in its duties.

[ORAC]

Time for the MOD to lose its Crown immunity? (http://blog.shesoftware.com/time-mod-lose-crown-immunity)

[Chugalug2]

roving, we are all only too well aware of Crown Immunity. Even if that were not the case, the problem here is that Sean Cunningham's aircraft was unairworthy because the UK Military Air Regulator, the MAA aka the MOD, had failed in its duty to ensure otherwise. The apologists as ever want to ram a stovepipe onto this tragedy, just as they did with the Mull Chinook, the Iraq Hercules, the Afghanistan Nimrod, and every other airworthiness related fatal air accident that have accounted for some 75 lives in such accident threads in this forum alone. Rather than wanting to set heads on spikes, be they JO pilots, SOs and 1* VSOs, or Company CEOs, we need to wrest Regulation and Investigation from the maw of the MOD, and make them independent of it and of each other. Unless and until that happens the urgent reform of both processes will be stillborn. More people will then die needlessly in unairworthy UK Military aircraft. Let the Crown be immune, just stop the cover up, admit the actions that led to this scandal, and allow proper reform to start. Time is of the essence (as no doubt you would be prone to say), for the longer this mess continues the longer that UK Air Power is fatally compromised.

[[email protected]]

Hear, hear, :ok::ok::ok:

[roving]

Chugalug2, I am with you on all of that.

I was not simply being pedantic but underlining, once again, the fact that the Crown's immunity absolves it from penal consequences for its sins of commission and omission whilst others without immunity are hung out to dry.

[RetiredBA/BY]

Bob Viking, can you please tell us WHY zero-zero seat pins (MDC too?) are replaced on the move these days?

Surely it would be better to do so only when stationary and before unstrapping?

Hear, hear to that. Sorry, Viking, it's not time to put it to bed until we have the reason for the change to long tried and tested procedures . Who, CFS, 4 FTS, HS, MB, Boscombe, or REDS, and why?

I would argue , to any forum, that replacing a seat pin without a visual checK of correct insertion, is dreadful practice, even more so if the aircraft is moving and in close proximity to other moving aircraft.

Let's hope the RAF has changed this basically unsafe procedure.

I would ask too, does RAF engineering not require an independent inspector to sign off critical work such as the was done on the shackle before releasing it to fly?

"...and just for the record, I flew ejection seats for 12 years, ejected once, hence my close interest in this accident, and was senior standards QFI in my last unit, so not exactly an uninformed amateur in this matter.

[airpolice]

Hear, hear to that. Sorry, Viking, it's not time to put it to bed until we have the reason for the change to long tried and tested procedures . Who, CFS, 4 FTS, HS, MB, Boscombe, or REDS, and why?

I would argue , to any forum, that replacing a seat pin without a visual checK of correct insertion, is dreadful practice, even more so if the aircraft is moving and in close proximity to other moving aircraft.

Let's hope the RAF has changed this basically unsafe procedure.

I would ask too, does RAF engineering not require an independent inspector to sign off critical work such as the was done on the shackle before releasing it to fly?

"...and just for the record, I flew ejection seats for 12 years, ejected once, hence my close interest in this accident, and was senior standards QFI in my last unit, so not exactly an uninformed amateur in this matter.


You're wasting your time expecting Bob Viking to stop asking you to move along as there's nothing to see here.

Just like the incident a few months ago where a Hawk went completely dark, and quiet above cloud, Bob thinks we should just play nice and not make waves.

Obviously our lords and masters know better than us, that's why they are our lords and masters. So... when the VSOs tell us to face the front and shut up, we ought to do just that.

No good is going to come of looking for the truth, we already know what it is, and it has to remain a secret to protect the guilty.

[Bob Viking]

Tucumseh.

When I said “give it a rest” I was not referring to the broader discussion of airworthiness. I was referring to the “it wouldn’t have happened in my day” brigade. I have no problem with your discussion.

BEagle.

I have been flying on MB seats constantly since 2001. Since day one I have been taught to insert the seat pan and internal canopy handle pins during taxi back (stopping if necessary especially as an inexperienced pilot) and visually check them. The MDC unit pin is inserted after egress.

Newer aircraft also have a PINS caption on the CWP to indicate if the pin is inserted with the canopy closed.

Until recently (coincidence) we would also unstrap whilst taxiing. That practice has now ceased (which I disagree with).

Also remember that newer Hawks are able to taxi with the canopy open.

Retired BA/BY

I respect your experience but we did this to death a few pages ago.

I cannot tell you who made the change to procedures but somewhere between you retiring from the RAF and me joining, it happened.

It would not have been done on a whim and the same CFS that you and BEagle remember would have carefully reviewed the procedures.

Personally, I don’t want to be strapped into a live seat after landing. I can count several instances where crew (including myself) have had to perform an emergency egress where having the seat safe made for a quicker and safer exit.

FRCs will state during the emergency egress drills as item 1:

Seat pin...insert

I would argue that the chances of screwing that up are far higher when you are trying to exit in a hurry than they are during the taxi back.

Our opinions clearly differ but they are both based on what we were taught. A touch of confirmation bias for both of us perhaps?

I can assure you and BEagle that pins discipline has always been rigorously enforced and always will be.

Airpolice.

I have no beef with you but, please, grow up.

BGG.

Thankyou!

Did I miss anyone?!

BV

[tucumseh]

Bob Viking - Thank you.

Roving - I think you know that the persistent offences I mention are breaches of the Air Force Act (and its successors?). Making false record attracts a maximum 2-year sentence. I'm not just talking about the aircrew training records in this case, but the more serious and serial offences committed by those who knowingly signed to say they had personally ensured a valid safety case existed, when a succession of Service Inquiries have revealed they did not. That is a legally binding declaration, and the false declarations resulted in numerous deaths in aircraft that had no legal Release to Service. Chinook. Tornado. Nimrod. Sea King (albeit, it was very nearly right). C-130. Hawk. That is not an isolated instance. Those cases alone span 17 years. In my opinion, that indicates a very serious organisational failure, which MoD seems completely ambivalent towards. Not 'seems'. Confirmed, in writing.

[tucumseh]

Yes there was a problem, but what makes you think you have any righ to know about it?Public interest. 'Safety of public whom the aircraft overflies'.

good practice always evolves.Not always. See previous post! The policy is good. The implementation is lacking. Nimrod Review in a nutshell.

[NutLoose]

Just a simple 'Feeler gauge' check for enough gap to ensure freedom of movement, if the bolts the wrong size then change it. Just don't clamp things together because the instructions tell you to.

How simple is it to have a properly engineered 'Gap' by feeler gauge, not all this 'Torque loading a bolt' so it's in 'Safety?' Just 'winding it up until the thread, or thread & a half shows through & clamping parts together as a result.

As I said much earlier, pilots used to 'Rackle the shackle in my day, to ensure that the shackle was really free.

That there would be a dangerous precedent, because the minute you start to ignore the written instructions / manuals, the whole lot for the aircraft might as well be slung in the bin... just because it tells you in the written instructions that you can lift off in 1000 metres with a maximum of XYZ fuel onboard, do you double that fuel load and ignore the book on a 1000 metre runway?

[airsound]

BigGreenGilbert - tuc is of course right when he points out the safety of the public as one reason for us all having a right to know about the Dark Hawk. I certainly don’t want to find myself wearing a Hawk of any kind when I’m just walking along minding my own business.

But there’s surely a moral reason as well. That Dark Hawk is public property - our taxes paid for it. There are probably only three reasons why we shouldn’t be allowed to know the details - confidentiality involving either personal privacy or commercial sensitivity, and national security. As far as I know, none of those applies here.

Does it not occur to you that yourwhat makes you think you have any righ to know about it?displays the kind of arrogance that still expects unquestioning deference for superiors (of which perhaps you may be one)? I believe those attitudes should have disappeared years ago.

airsound (who's sorry for the thread drift)

[Flight_Idle]

That there would be a dangerous precedent, because the minute you start to ignore the written instructions / manuals, the whole lot for the aircraft might as well be slung in the bin... just because it tells you in the written instructions that you can lift off in 1000 metres with a maximum of XYZ fuel onboard, do you double that fuel load and ignore the book on a 1000 metre runway?

I worded that rather badly I'm afraid. I should have said "If the instructions are clearly dangerous, refuse to carry out the job & report the matter to higher authority.

[Stitchbitch]

JTO the phrase same but different applies. IIRC the Typhoon Flight Jacket (LSJ/LP) uses Kevlar reinforced Arm Restraint Extension Lines attached to the jacket sleeves (these plug into the seat QRB - QRF in old money), unlike Tornado, where the arm restraint lugs are attached to the jacket arm and the restraint lines were part of the seat (?).

I'd like to say that what happened to you friend wouldn't happen today, from experience the kit is tested to the nth degree via high speed wind-blast testing, live ejections, 'wet drills', burn tests, etc.

[NutLoose]

Flight Idle,

Again that can be a dodgy course, say you think it is overtightened and XYZ chief tells you ignore the book and XYZ is wrong, you are carrying the can for your actions in not following the laid down procedures. I know, it seems wrong, but thats how it is, also look at the other thing, if the aircraft is needed how long does it take to pass this up the chain and assuming it does not get stopped on route, to get a reply from the manufacturer and a response back down that chain.
Civi Wise I can contact my Manufacturers rep who will contact the Company design team and I can have an answer emailed to me in a couple of days.

Though sadly the CAA of late have allowed parts of the maintainence manuals to be ignored, that in my eyes is a disaster waiting to happen, as a piecemeal approach leaves what to do and what to ignore up to the individual as opposed to you having to follow it all.

[tucumseh]

I can have an answer emailed to me in a couple of days.Quite right N. MoD did have such a (mandated) process, but we were told to cease it in June 1993. It's still used, entirely unwittingly(!), by a flagship Infantry programme. But I've seen a recent Aircrew Survival Equipment contract that doesn't call it up. Presumably nobody in the IPT realises the contract is a crock as they posted it on the internet. The process is simple. Named engineer at Air Station in contract (it was a C/T at Wyton, for example, on Nimrod R SRE). Design Authority could accept a phone call from him, and intermediately start work without further approval; up to a specified limit which equated to man-hours. This gave the Technical Agency time to formalise. Commercial or Finance not involved at any point. On R, there was sliding scale as an incentive. Big bucks if you cracked it that day. Less if 24/48 hours, and so on. SFA if you screwed up.

[glad rag]

A technician over-tightened a nut.

PDR

Easy to say.

As nutty and others have alluded to, the problems are still with us even now and nothing is being done to ensure issues like these are PREVENTED in the first place.
First port of call?
Skill of hand. Followed by an enquiring mind.
Basic, basic stuff.
Is it too much to ask?

[airpolice]

Here is the threat. Childish as my views may seem to Bob, this is not about my right to know, it's about everyone's right to have everyone know. Telling the world why that Hawk went dark is not a threat to national security, however it might well be a threat to commercial opportunities for the people at Warton.

Despite the clear rules, people eventually do things in a different manner, and for a while it's all good. Then someone dies, and in the aftermath, we learn (again) the lessons of years ago.

We all know about the foam in the C130 fuel tanks, so there is little or no chance of a C130 going into a combat zone without that and nobody being aware.

The situation with the Hawk T2 however.... Imagine the scene in 15 years from now, and three contractors later, nobody still on the flight line at Valley from last summer.

Because it has been kept quiet, nobody talks about it, so it never gets passed down the line, and the same bad practice creeps in, for the same reason that it crept in last time.

A solo student is caught out, this time at night, and he (understandably) collides with an airliner.

Who are the MoD going to blame that on?



Back to the thread topic.....

I might have misunderstood, but I thought that, and I'm happy to be corrected here, MB have declared that the seat failed because the RAFAT mechanics failed to service the seat properly,

In a statement issued by the firm after entering the guilty plea, it said: "It should be noted that this was an isolated failure relating to the tightening of a nut during maintenance procedures conducted by RAF Aerobatic Team mechanics."

yet the report said the last work on the seat was carried out at Valley on 24th October.


On the basis that I'm right there, am I also right to say the RAFAT mechanics are in blue suits (literally) and the Valley people are civilian contractors? I'm genuinely asking, I've not been to Scampton, or Valley, for years.


As for the SI report, I found the bit at 1.4.5.23a & b quite interesting.

Section 1.4.5.24 directly contradicts Gilbert's assertion that good practice always evolves.


The term used is "incorrectly authorized deviation" when discussing the fact that the Reds had rules, that were not compliant with what had been agreed and written down, by the people responsible for agreeing and writing down the rules.

Why is it so hard for the RAF to find **** like that before someone dies? What on earth is going through the heads of people making changes to procedures, and not getting approval? How can anyone give approval without having checked the impact of the changes.

As for.......

"The positive picture of flight safety and the state of publications and pilot log books appears to be contrary to the findings in this Section.

It is the Panel's view that the Formal Staff Visit may not have provided the AOC with an accurate picture of the RAFAT upon which to base his report."

Sometimes you need to say it very clearly. Either the RAFAT suddenly went off the rails, big time, just after the AOC's inspection, or there wasn't much real inspecting getting done.

[Easy Street]

I’m astonished at M-B’s guilty plea. Even assuming the company couldn’t prove that it had informed MoD of the risk of over-tightening in 1990 (along with all the other users), its lawyers must surely have been aware of the 2002 QinetiQ report? The latter date rings true to me for another reason: undergoing a course on a Mk10-equipped aircraft around that time, I distinctly remember the ground school instructor advising us to give the drogue shackle link a ‘wiggle’ to check it wasn’t pinched. Unless this had always been part of Mk10 groundschool patter (can’t remember that far back!) then intra-MoD awareness of the 2002 report would explain why the potential fault was highlighted.

[tucumseh]

Easy Street

Well said.


The HSE charges were 'catch all', and specifics were not revealed until very late in the day; probably why M-B pleaded not guilty last year. It emerged in October that the two charges related to (a) quality of design, and (b) failure to send out a technical bulletin in 1990. The legal strategy dreamed up by their solicitors was 'don't upset MoD'. The quality of product charge, for obvious reasons, was the one to concentrate on.

The company statement (posted by airsound the other day) implies the quality of product charge was dropped. Those in court confirm this, although the way it was presented was apparently vague. If true, and even if guilty, the paperwork one would be a minor administrative error. (The allegation relates to 1990, but even the SI report admits the information was known by the correct people in 1991). The problem the company created for themselves was that media and public opinion was already tainted by the Coroner's inaccuracies and ill-informed comment - caused in part by MoD concealing relevant evidence, including the 2002 report. M-B and their solicitors have a copy obviously, but the strategy meant it wasn't used. I think this poor, because it would have cleared them of both charges.

(Remember, the SI report was not published until after the Inquest, and the MAA issued a written statement five days after evidence had finished that the family had only just been given a copy. Nobody could possibly prepare a case in time against MoD's version).

This report is actually a catch-up exercise by QQ, as MoD required independent safety assurance for Mk10A seat mods that had been developed and trialled in 1998, as a result of the 1996 Tornado Airworthiness Review Team report (TART). The mods were approved in 1999, but lacked an audit trail. One mod negated the risk of over-tightening the nut. This report closed the loop. The TART report is also what clears M-B on the paperwork, the Director of Flight Safety repeating his 1992 criticism that dissemination of safety information by the RAF was poor. (MoD denied the existence of TART for many years; and in this Hawk case MoD claimed no knowledge whatsoever of when the mods were developed or why. This lie was repeated in the House. You always follow the lie).

All this was too late for M-B, and it is plain the senior Director made an executive decision to plead, and get it over with. This was made very recently, because even a few days before the court appearance former MoD employees were standing by to give evidence, having been sought out by the solicitors (not come forward themselves).

Hope this helps. It will be interesting to hear what's said in court next month, if reported. Regardless, the truth will be published!

[Easy Street]

tuc, thank you for the insightful reply.

‘Don’t upset MoD’ seems to me a disastrously misguided strategy. What would MoD do if upset? Buy American or Russian? Mount a disinformation campaign to scupper M-B’s overseas sales? With the idea of a UK industrial strategy being in fashion that’s politically unthinkable. It’s probably legally impossible too. On the other hand, the damage inflicted on the company’s reputation by the guilty plea is very real. Unless I’m missing something crucial this is a woeful misjudgment by M-B.

[tucumseh]

Easy Street Fully agree.

[EAP86]

I’m astonished at M-B’s guilty plea. Even assuming the company couldn’t prove that it had informed MoD of the risk of over-tightening in 1990 (along with all the other users), its lawyers must surely have been aware of the 2002 QinetiQ report? The latter date rings true to me for another reason: undergoing a course on a Mk10-equipped aircraft around that time, I distinctly remember the ground school instructor advising us to give the drogue shackle link a ‘wiggle’ to check it wasn’t pinched. Unless this had always been part of Mk10 groundschool patter (can’t remember that far back!) then intra-MoD awareness of the 2002 report would explain why the potential fault was highlighted.

There is a view in some circles that if the HSE elect to bring a charge in court under the HASAWA, it is extremely unlikely that the charged party would be found not guilty despite the cogency of the evidence. These views are often associated with a story where this has been the case of guilt being found despite strong mitigating evidence. I've heard some of these stories but I must confess I've never researched their accuracy. Ultimately it is MBA's insurers who will have the strongest influence on whether to plead guilty or not and cost/success is an issue.

As regards the product design quality charge, I suspect that it may have been dropped because of a difficulty in determining, after many years in service, how much of the design could truly be assigned to MBA's responsibility. I can think of many instances of designers' preferences for in-service fixes being 'discouraged' by PTs etc. Warnings, procedures, instructions, training etc. being cheaper are often preferred over proper modifications. In the safety world they have a desirability order of priority for fixing safety problems and 'elimination' of the hazard always comes first in the order.

BTW this isn't to say that PTs don't need to have a strong influence on matters. Unfortunately the HASAWA contains separate duties for designers/manufacturers and operators and this wasn't well recognised in MAA regs. Industry did make representations on this to the MAA on several aspects of the regs but from memory (warning: may be faulty these days) the only outcome was some words in Def Stan 00-56 to the effect that compliance with the Def Stan does not necessarily mean that parties' legal duties are satisfied. This lack of clarity was a driver for a certain engine company issuing so-called 'duty of care' letters to try and mitigate their own liability situation. Unfortunately, many believe that such letters can actually make it worse.

EAP

[tucumseh]

EAP86

Excellent observations. Had the case proceeded on the quality of product charge, and if M-B had chosen to defend themselves, there would have been much commonality in the defence to both charges. One being that the seat was serviced to an illegal / rogue Routine Technical Instruction, devised and issued by MoD and in breach of every know regulation. The fact is, by its own admission MoD was well aware of the information it claims M-B did not provide, and did not incorporate it in the RTI or, it seems, training.

[Wander00]

I think (IMHO, sadly) MB have taken a pragmatic commercial decision to take the hit and get on with life. However, I am saddened that MoD has not taken responsibility for obvious failings on their part and fessed up. It is obvious that responsibility has to be taken for this unnecessary death, but it would appear that more blame attaches to MOD than MB, whose excellent product has saved very many lives.

[walbut]

Although the HSE cannot prosecute the MoD, even in the event of a fatal accident, it is very surprising to me that they have not censured them, which they are at liberty to do. I agree with many of the posters in this thread, it seems much more of the liability for this tragic accident lies with MoD, rather than Martin Baker.

From a vendor aspect, the situation with regard to service bulletins on Hawk equipment could be confusing. Every export Hawk instruction would normally go through BAe Systems to the customer. However since the UK MoD dealt directly with Martin Baker on all aspects of the T Mk 1 seat design and mod standard, BAe Systems would not try to read across the export instructions to the T Mk 1 and advise MoD as they would assume MoD had been sent an equivalent instruction directly from Martin Baker. Whether Martin Baker did that and it went missing in MoD I have no idea.

I have to confess I cannot remember seeing the equivalent export service bulletin but someone in Flight Systems or Airworthiness at Brough could probably find a copy with my signature on the covering form.

Walbut

[Distant Voice]

Does anyone know what the current situation is regarding the type of shackle fitted to the Red Arrow Mk10 B ejection seats. Is it gas or scissor?

DV

[CAEBr]

The RAF Hawk TMk1 fleet still have the original standard Mk10 seats with the scissor shackle. The broadly similar seats in the Tornado fleet were modified a few years ago to incorporate the gas shackle. The Hawk TMk2 fleet have the newer lightweight seats with the gas shackle.

CAEBr

[Lordflasheart]

For those who missed it - Lincoln Crown Court, 12 and 13th Feb.

A bit of to and fro during the two days pre-sentencing hearing. Speeches for the prosecution and defence as reported by the Beeb 12th -

Red Arrows death: Ejection seat firm 'put lives at risk' - BBC News (http://www.bbc.co.uk/news/uk-england-lincolnshire-43031833)

and 13th - Red Arrows death: Ejection seat failure a 'once every 115 years' event - BBC News (http://www.bbc.co.uk/news/uk-england-lincolnshire-43044909)

and rather more luridly in the Daily Express.

M-B has already agreed to pay £550,000 prosecution costs.

Adjourned to 23 February for sentencing.

..................

[tucumseh]

It appears the 'quality of design' charge wasn't dropped, per se, but HSE conceded (for some extraordinary reason) that CAD wasn't available to Martin-Baker in 1947. Better to say HSE agreed the level of severity was lower than at first implied.

This doesn't detract from the fact that the offending design, and the resultant risk of the Scissor Shackle/Drogue Shackle jamming due to nut over-tightening, was designed out in 1990, but MoD declined to adopt the modification in Hawk. The 1 in 115 years calculation was not adjusted when poor training and engineering practices developed. In any case, the existence of a minor mod that eliminated the risk altogether, meant MoD bore a risk in Hawk that was not ALARP.

I understand the judge expressed uncertainty as to what to do. Hence, the 10 days to think. She was less than pleased at M-B's last minute change of plea. A few days previously, having been informed of evidence concealed by MoD, she had the sense to call it forward. But she didn't ask why HSE had proceeded in the face of this evidence, which raised considerable doubt over the safety of the prosecution. Perhaps she's just got to accept they pleaded.

It will be interesting to see what she does. I keep thinking of this...

1. 56 of the SI's 60 recommendations were mandated policy.
2. All 17 contributory factors were MoD liabilities.
3. Of the 3 aggravating factors, 2 were MoD liabilities, and one shared with M-B.
4. Of the 6 other factors, 5 were MoD liabilities, and one shared with M-B.
5. All 13 observations were MoD liabilities.

[oldmansquipper]

Interesting indeed, tuc.

IMHO, I hope that judgemental common sense will prevail and the sentence when it comes will be 'ALARP' in it's own right.

MBA do not deserve this.

[roving]

The Judge is in fact the Senior Presiding Judge for the Midlands Circuit. To military types a when a High Court Judge is appointed, after the 'first tour' they are often appointed as a Presiding Judge of one of the Circuits. This a 4 year tour. 2 as Junior Presiding High Court Judges, followed by 2 as the Senior Presiding HCJ. The senior presiding HCJ has both great power and great responsibilities. Amongst other powers is the power to choose which cases they will sit on.

Before appointment as a High Court Judge she was Queens Counsel specialising in professional negligence and product liability.

I suspect that when she posted herself to Lincoln, she did so to take personal charge over what was expected to be a three week very high profile trial, with potential far reaching consequences, especially if MB's defence was that a large part,if not all, the fault lay with the MoD.

She would have been fully aware of all the nuances arising in this case.

However the decision of MB to enter as plea of guilty may not merely have caused admin problems for those who organise her lists, but now requires her to decide what financial penalty must be imposed on this very highly respected company and what observations she must make when sentencing.

Rather her than me.

[Distant Voice]

What do we know ?

(1) Early 1980s, Martin Baker recommend shrouds over firing handles, MoD decide not to fit them.
(2) 1983 MoD offered a retrospective shroud on the Hawk which was refused.
(3) Drogue/Scissor jamming can be caused by a least two events (a) over tightening of the bolt, (b) geometrical lock.
(4) In 1990 gas shackle was being fitted (Court evidence)
(5) Mod offered for Hawk was offered all round the world, none has taken it up. (Court evidence)
(6) MoD regarded risk as being 1 in 115 years (Court evidence)

Now let's join the dots together

(1) Around 1990 the possibility of jamming because of bolt over tightening became known about, so the gas shackle was introduced.
(2) The gas shackle was fitted to all seats leaving the factory from that time. This explains Canadian Hawks and Mirage III fits
(3) Martin Baker offered up a modification to all users for in-use seats; it was not taken up; probably because of costs.
(4) Mitigation was to ensure no over tightening.
(5) Around 1997 it was decided to upgrade the parachute on Tornado seat (Mod 2198). This required re-qualification trial by MB
(6) During the course of these trials (1998) a shackle jam occurred, but this time due to a geometric lock.
(7) This could not be ignored, so gas shackle modification became part of Mod 2198
(8) Gas shackle modification eliminated the two known causes of scissor shackle jamming on RAF Tornado.
(9) 2002, review of the trials programme for Mod 2198 issued by QinetiQ. Customer Ref No. suggests that tasking was made in 1997.
(10) Gas shackle modification not read across to RAF Hawk T1s flown by Red Arrows ( suspect cost and low risk; 1 in 115 years)
(11) All RAF Tornado a/c modified (Mod 2198) between late 2007 and early 2012 (latest). No mention of gas shackle just parachute upgrade.
(12) 8th Nov 2011, Flt Lt Cunninghan initiates ejection sequence after strap misrouted through firing handle.
(13) Flt Lt Cunningham died when parachute failed to deploy because of one of the jamming causes (over tightening of bolt)
(14) November 2011 (after accident) MB issue SIL 704, making it clear that there was not an issue with gas shackle seats.
(15) SI panel examines evidence including references to Tornado zero/zero ejection problems and gas shackle.
(16) Final SI report, supervised by MilAAIB, makes no reference to Tornado ejection problems and gas shackle.
(17) No mention of Tornado ejection problems and gas shackle at inquest.

Bottom Line

Had Flt Lt Cunningham's seat been fitted with a firing handle shroud the ejection sequence would not have been initiated. Had his seat been fitted with a gas shackle he would have survived the ejection, perhaps with two broken legs, but he would have survived.

What has Martin Baker done wrong? Martin Baker hold the Ace, King and Queen of trumps, so why did their Defence QC not play them on 13th Feb 2018? Was someone holding a gun under the table. Sincerely hope that the Judge sees through this farce.

DV

[Chugalug2]

DV:-
Sincerely hope that the Judge sees through this farce.

I wouldn't hold your breath. Everyone who has officiated in the long running scandal of UK Military Airworthiness has failed in their duty, with the honourable exceptions of the Oxford Coroner and those who have testified in this forum. Apologists, VSOs, MPs, Ministers, a Deputy Chief Constable, an RAF Provost Marshal, QCs, the RAeS, all have known which side their bread is buttered and decided that it was someone else's problem despite the overwhelming evidence supplied to them that RAF VSOs subverted UK Air Safety in the late 80s/early 90s to such an extent that it is still utterly dysfunctional and unairworthiness affects the entire UK Military Airfleet. Sean Cunningham was the 74th person to die in airworthiness related fatal air accidents featured in this forum because of this scandal. Thanks to the MOD's continuing cover up of the scandal he sadly will not be the last.

[roving]

Distant Voice, the QC would have been acting strictly in accordance with his instructions. If MB took the view that commercial expediency outweighed any other considerations, that was their decision and their's alone.

[airsound]

roving, I agree with you when you say the QC would have been acting strictly in accordance with his instructions.After the hearing I asked the defence barrister, Richard Matthews QC, if he had known about the 2002 QinetiQ report (the one that included the words “… failure of the main parachute system to deploy due to ... scissors shackle … [was] successfully eradicated by … GS drogue bridle release system …” (the so-called ‘gas shackle’)), and he said he had seen it. But it had not been mentioned in the hearing.

I had sat through both days of the hearing, the prosecution on the Monday and the defence on the Tuesday, and the judge’s summary remarks when she said that this had been a most unusual sentencing event. Indeed, she admitted she wasn’t sure how she was going to progress. Which was presumably why she is taking ten days to decide on sentence.

May I take a little diversion here? If, like me, you sometimes look at the pages of PPRuNe and despair of your fellow aviation professionals, then this page of this thread is exactly the thing to renew your faith. It is packed with thoughtful and experienced expertise, the like of which you would be hard put to find in the same place anywhere else.

Keep up the good work, troops!

airsound

[Distant Voice]

If MB took the view that commercial expediency outweighed any other considerations, that was their decision and their's alone.

That could be the case, but this trial, brought about by HSE has to be about serving public interest. It is not in the public interest, or most importantly those of the Cunningham family, if the judge does not take action. I am not a lawyer, but it is my understanding that;

(1) As the law stands at present the judge (or magistrate) are permitted - and sometimes expected - to intervene on their own initiative when it is necessary to prevent the normal adversarial process resulting in inaccurate fact finding and consequent injustice.

(2) Where after a guilty plea the prosecution and defence present an "agreed version" of the facts for the judge to sentence on, he/she may reject it if he/she thinks it is implausible and have his/her own investigation.

DV

[Distant Voice]

After the hearing I asked the defence barrister, Richard Matthews QC, if he had known about the 2002 QinetiQ report

You bet he did. Clyde and Co were sent a copy of the report on 31st Jan and Martin Baker on 30th.

DV

[roving]

(2) Where after a guilty plea the prosecution and defence present an "agreed version" of the facts for the judge to sentence on, he/she may reject it if he/she thinks it is implausible and have his/her own investigation.

DV

To draw an analogy. Back in the day when someone was charged with murder, the DPP or the Attorney General had to approve any proposed plea to a lesser offence, for example manslaughter on the grounds of diminished responsibility. If the DPP or the Attorney General gave his approval, that was the basis of the case. I know of only one case where a Judge has refused to accept such lesser plea. That was the Yorkshire Ripper case, where Mr Justice Boreham refused to approve it. Ultimately there was a trial and Sutcliffe was convicted of murder.

When, in 1981, it was reported that the attorney general Sir Michael Havers had accepted the consensus of medical opinion that the Yorkshire Ripper Peter Sutcliffe should be allowed to plead guilty to manslaughter on grounds of diminished responsibility, it was not a course of action attractive to the general public, who believed that Sutcliffe had "got away with it".
Nor did it appeal to the trial judge Sir Leslie Boreham, who has died aged 85. He thought that Sutcliffe might have deceived the doctors, and that the medical evidence should be tested by a jury. After several hours of legal argument, Havers changed his position, and the trial ended with Boreham sentencing Sutcliffe to 20 terms of life imprisonment, recommending he should serve at least 30 years.

https://www.theguardian.com/news/2004/may/12/guardianobituaries

[tucumseh]

Roving is right about the QC. My opinion is that M-B were not served very well by their solicitors.

It is also my opinion that any law firm ostensibly specialising in health and safety, and representing a military aviation firm, should ensure their solicitors have at least heard of the Nimrod Review. If they have not, one can put very little of the evidence in this case in context. That gave me a sinking feeling at the time. I'm glad a good friend was there to witness it, because no one would believe it.

Well said airsound.

[dragartist]

I think someone should be charged with Perverting the course of Justice.
Can’t see how justice is served by MB taking one for the team.

[Lordflasheart]

Quote 7th November 2017 -

“The Directors are saddened that a case against the Company has been brought by the Health and Safety Executive (HSE). The case relates to the circumstances surrounding an accident with an ejection in November 2011. The ejection seat concerned was designed in 1972 and delivered in 1976. In the intervening years the seat had been maintained under RAF control with none of the servicing being performed by the Company, however the HSE alleges that the Company had a duty to warn about risks in the procedures used in the maintenance and operation of this type of seat.

On the evidence presented by the Prosecution as at 11 October 2017, it is the legal opinion of both Clyde & Co and Defence Counsel that there is a realistic prospect of the Company successfully defending itself at trial and that it is probable i.e. more likely than not, that the Company will be successful at trial. The trial is listed for 5 weeks at Lincoln Crown Court commencing on 21 January 2018. A not guilty plea has been entered and the matter is being fully prepared for trial.”
LFH
.................

[Just This Once...]

Some of that list is dubious or positively misleading. The mitigation for the seat firing with the pin in was not the shroud - it should have been designed so that the pin could only be inserted in a safe position (although I have never been keen on pins in the first place).

The shroud was an awful idea, previously used on earlier seat designs before being modded out as it made the seat handle difficult to grasp - a massive safety issue. The original Mk10 handle was also pathetically small in the first place and it took the burning to death of one very fine chap before the size was increased (mid-90s) with a bigger loop so that it could actually be grasped with the stick fully aft.

Finally, the gas piston design change on the Tornado was not driven by the shackle issue. The original shackle issue should have been mitigated at the design stage with a shouldered bolt or similar. Fitting a different shackle/bolt combination would have been a cheap and simple forward line fix. Heck, if MB really did have concerns they could have retired the old design on safety grounds and only supplied a shouldered bolt design.

Oh and probably worth remembering the other ejection seat deaths with the heavy hand of MB design issues (Harrier, F-3, GR4, Spanish Typhoon to name a few), or the near-misses spotted by MB during post-accident inspections but not passed to the accident investigators or end users. If MB had fought this case the scale of the wider issues would have come tumbling down.

[Distant Voice]

If MB had fought this case the scale of the wider issues would have come tumbling down.

That is what everyone wants.

DV

[tucumseh]

The shroud was an awful idea, previously used on earlier seat designs before being modded out as it made the seat handle difficult to grasp - a massive safety issue. This highlights the compromises needed in such a design. And it is not a normal iterative design. You hope not to have repeat cycles to analyse. The fact is their basic design evolved to a point, 28 years ago, when the risk that materialised in November 2011 was eliminated altogether. M-B changed their base design for new seats, but could not do this retrospectively. MoD needed to adopt it, but didn't. There may have been good reason, but MoD tried to hide it, actively concealing evidence. The HSE admitted they had not seen it.

What few seem willing to accept is that if the seat is needed, it means all the other layered defences have failed. The only difference here is it was an uncommanded ejection. The parachute should still have deployed. If the assembly instructions, trade training and good old common sense had been followed, it would have. That doesn't make it a bad design. The other defences broke down. All were MoD liabilities. MoD admitted this.

As DV says, those wider issues need to be exposed. As matters stand, the root causes have been swept under the carpet, again.

Mrs Justice Carr says she has a problem determining what to do. I suggest she speak to Charles Haddon-Cave.

[Distant Voice]

Some of that list is dubious or positively misleading. The mitigation for the seat firing with the pin in was not the shroud - it should have been designed so that the pin could only be inserted in a safe position (although I have never been keen on pins in the first place).

Every statement on that list can be backed up with hard evidence, it is not opinion. The shroud was not meant as mitigation for the pin, but to prevent misrouting of the straps through the firing handle. What mitigation was put in place once the MoD/RAF decided to remove it? I understand that customers around the world accept Martin Baker seats with shrouds in place to mitigate the risk created by misrouted strapping.

Since Flt Lt Cunningham's accident, improvements to the shroud have been designed by Martin Baker and offered to the UK MoD for the Hawk but were rejected. As of April 2014 two further revised shrouds had been presented to the UK/MoD for evaluation but had not been accepted.

Finally, the gas piston design change on the Tornado was not driven by the shackle issue.

Clearly, you have not read the 2002 QinetiQ report covering the testing of Tornado modification 02198. In addition to what Airsound said earlier, the report makes it clear that, "Due to the failure of the MBA trial in mid October 1998, the scissor shackle mechanism was replaced with a GS a drogue bridle release system, incorporating modifications to the BTRU and GFTDU"
The introduction of the gas schackle became part of modification 02198.
DV

[EAP86]

Just for a bit of context on the seat mods for Tornado, during the latter half of the 90s there were many Tornado seat mods going through the system; I think the term used internally was "the six pack".

The main driver for these mods was the fact that many RAF pilots fell outside of the 3%ile to 99%ile cleared anthropometric range. When the problem had first arisen, the RAF had approached MBA for an assessment and the immediate outcome was a strangely shaped envelope in the RTS limiting where ejection was cleared. The mods, including a new main parachute (GQ5000?), had to be embodied to return to the larger, simpler cleared envelope for all aircrew.

Its around 20 years since I looked at the mod documentation and I confess I have no recollection of issues with the scissor shackle. Part of the problem may have been due to the RAF dealing directly with MBA and not via the Panavia Partner with design responsibility for the ejection system. This did cause difficulties with respect to trying to consider the interests of the other Tornado operators.

I can't say I recall a 2002 QinetiQ report on this subject but the date suggests it was finalised a fair time after the various mods were designed and qualified. Perhaps the Panavia/MBA records might help substantiate the QQ assertion wrt to MOD02198's purpose?

EAP

[Distant Voice]

I think the term used internally was "the six pack".

Mod 02196 introduced a taller headbox and a new head pad with improved impact attenuation properties. Mod 02196 also saw the introduction of steering lines to the GQ1000 Mk1 parachute which resulted in the GQ1000 Mk2.

Mod 02200 saw the introduction of a simplified restraint harness with a parachute steering facility, to permit integration of the GQ1000 Mk2 steering lines (Mod 02196) and allow the aircrew to strap in unassisted.

Mod 02197 involved the replacement of the primary and secondary ejection gun cartridges.

It would seem, according to the BOI report into the loss of Tornado ZA554, that mod 02198 was split into mods 02198A and 02198B. Mod 02198A introduced a new drogue withdrawal line and protective top flap. Mod 02198B introduced a new parachute (GQ5000), a gas operated shackle and associated pipework, and a gas fired BTTDFU and associated timing mechanism. It should be pointed out that the gas shackle and modified BTTDFU, which became known as the GFTDU, where not part of the original MoD 02198 but became necessary after the scissor shackle failure in Oct 1998.

DV

[lsh]

There is so much knowledge on this, and the previous, page - I do so wish it could all be submitted to the court.

As to the root cause - I feel there are several root causes.

When that seat fired, the poor man should not have lost his life.
He (and others) may have made contributory errors; but the event should have been survivable.

lsh

[WHBM]

As a prominent QC once said to me (and others in a presentation) :

"Do not confuse the Law with Justice. It is a game played between skilled professionals, each with their own agenda which generally do not coincide, where those who were actually involved merely are spectators".

He also made the point that where the various participants may include more than one department of government (eg the Min of Justice appointing/promoting judges, and another Ministry being part of the story) that the permanent secretaries of the two ministries are likely longstanding chums and have probably sewn up between them what is best from the perspective of the government, how their own departments are seen within it, and what impact any adverse press comment coming from the case might have on them.

An upside here is the Lady Judge is very unlikely to be a mason.

[The Old Fat One]

"Do not confuse the Law with Justice....

Indeed, and don't confuse either of those with "the truth". As anybody who has seen the internal processes of a British Court of Law (military or civil) will swiftly agree.

[tucumseh]

WHBM

(eg the Min of Justice appointing/promoting judges, and another Ministry being part of the story)

Very true. The recent chair of the Defence Select Committee was appointed as a Justice Minister last month. In both capacities he was fully aware of the evidence that could have cleared M-B.

[Distant Voice]

As matters stand, the root causes have been swept under the carpet, again.


I understand that in the Tornado case (collision over the Moray Firth on 3dr July 2012) the root cause was avoided. The SI panel were advised by the MilAAIB to make the cause as bland and generic as possible, which in turn led to DG MAA (Air Marshal Garwood) attributing a fair amount of bad luck to the accident.

It is probably worth pointing out that the Tornado SI was taking place at the same time as the Hawk SI; same MilAAIB "specialist" advise/direcrtive.

DV

[roving]

Being pedantic, I think the military air accident agency has been rebranded as

The Defence Safety Authority

Which defines its role as

(A)n independent organisation, empowered by charter from SofS to undertake the roles of regulator, accident investigation and Defence Authority for safety.

The DSA was formed on 1 April 2015 and draws its authority from a charter signed by the Secretary of State (SofS). It has 3 roles:

firstly, it regulates safety across defence in terms of aviation, nuclear, maritime, land, ordnance and explosives, and fire
secondly, it is responsible for investigating defence accidents
thirdly, it is the Defence Authority for safety (including health and environmental protection)

https://www.gov.uk/government/organisations/defence-safety-authority

https://www.gov.uk/government/organisations/defence-safety-authority/about

[oldmansquipper]

DSA? Missed that. What is the average staff tour length these days so I can be prepared for the next change. 😉

[Chugalug2]

roving:-

Being pedantic, I think the military air accident agency has been rebranded as
The Defence Safety Authority
Which defines its role as
(A)n independent organisation, empowered by charter from SofS to undertake the roles of regulator, accident investigation and Defence Authority for safety.

I admire your sardonic sense of humour, roving. Apart from the fact that it confirms that Regulator and Investigator are one and the same (very convenient for the Regulator of course), it is part of the MOD. So independent of who exactly, the tea lady?

[roving]

I admire your sardonic sense of humour, roving. Apart from the fact that it confirms that Regulator and Investigator are one and the same (very convenient for the Regulator of course), it is part of the MOD. So independent of who exactly, the tea lady?

I think we may have to wait a long time for it to blame itself

[Chugalug2]

Well exactly, roving. Unfortunately for its scapegoats, a law unto itself.

[airsound]

roving and Chug

Being a tad more pedantic, it seems to be even more complicated than you might think. The MAA (Military Aviation Authority) has been subsumed (Yes, Minister) into the new-ish DSA (Defence Safety Authority). But what used to be the MilAAIB (Military Air Accidents Investigations Branch), which was part of MAA, is now a separate team called Defence AIB (Defence Accident Investigation Branch). It's colocated with the (civil) AAIB (Air Accident Investigation Branch), but I seem to remember that it has a "figurehead director", or some such bollox, in the DG DSA. I can't find the reference to that now....

Hope that's clear. Questions? (My head hurts.)

airsound

[Chugalug2]

Hot off the press as ever Airsound! I hope that the MOD sign-writer is well ahead of Google, which ascribes DAIB to something Chemical in German (not a very encouraging combination). Nonetheless, ASEMS Online (no, I don't know either) ascribes DAiB (very important the use of case in acronyms, of course) to the DSA, implying that it stands for Defence Safety Authority Accident Investigation Branch (but not explicitly of course).

No matter where it lives, no matter who it is collated with, if it quacks like a duck, it's a duck! The "figurehead" director is in the DSA, the DSA is in the MOD, thus the DAiB is part of the MOD. The goalposts must be getting pretty worn by now, don't you think?

https://www.asems.mod.uk/acronyms/daib

[Lordflasheart]

Back to Martin-Baker ? Quote ……. "Unfortunately for its scapegoats …."

The Martin-Baker annual report (signed by the Company Secretary) dated Nov 7th 2017 and date-stamped 7th December stated –
“On the evidence presented by the Prosecution as at 11 October 2017, it is the legal opinion of both Clyde & Co and Defence Counsel that there is a realistic prospect of the Company successfully defending itself at trial and that it is probable i.e. more likely than not, that the Company will be successful at trial. The trial is listed for 5 weeks at Lincoln Crown Court commencing on 21 (sic) January 2018. A not guilty plea has been entered and the matter is being fully prepared for trial.”
So what happened between filing the company report in November and mid January, to cause John Martin to change the plea to guilty ? I presume he didn’t just decide on a whim at breakfast on the 22nd Jan.

There would have been board meetings, meetings with Clyde & Co and Defence Counsel, who had told the board in October/November “… that it is probable ….. that the Company will be successful at trial.” Were there disagreements or were the ‘new facts’ sufficient to convince them all, against all the ‘old facts’ that have been well rehearsed on PPRune and elsewhere.

The Company Secretary was replaced a week before the trial, on January 15th 2018 but that might have been co-incidental because he’s still Secretary of the controlling parent company Killinchy Aerospace (formerly M-B Engineering).

However, Killinchy own all the shares of M-B Aircraft, including all voting rights and power to appoint and dismiss directors. Ten directors – the five of M-B, plus five others, own most of the shares in Killinchy. So was this a decision made (or nudged) by the controlling company ? Or was there improper pressure from elsewhere ? Or even a ‘guarantee’ of tenure at Chalgrove perhaps ?

What about the other four M-B Directors ? M-B Senior management ? What about the eight hundred or so M-B staff ? I wonder how they feel ?

Will there be scapegoats within the Company or is this to be recorded for posterity as a guiltless corporate crime with only the Company’s good name (and no other organisation or individuals) to bear the blame – and pay the price ?

Anyone have any ideas ?

LFH

..............

[Fortissimo]

No matter where it lives, no matter who it is collated with, if it quacks like a duck, it's a duck! The "figurehead" director is in the DSA, the DSA is in the MOD, thus the DAiB is part of the MOD. [/url]

We have been round this buoy before. By your logic, the CAA and the AAIB both work for DfT so the AAIB can't be independent of the regulator and must be corrupt (and all without a VSO in sight). Head DAiB has a direct line of accountability to SofS MOD, as does the Chief Inspector of Air Accidents to his SofS. It has to come to a point somewhere, so even if you put the DAiB in the Treasury, the PM is still in charge.

[tucumseh]

Fortissimo

The CAA and AAIB haven't lied in official reports, to bereaved families, Coroners or other legal authorities. MoD/MAA has, to protect itself. It has lied to Ministers, who (for the most part inadvertently) repeated them and misled parliament. The MAA doesn't even know why it was formed (MAA Technical Director, 13 July 2014). Or if it does, he lied. A common denominator emerges. With plenty of VSOs in sight.

[Chugalug2]

Fortissimo, tuc has replied on my behalf and better than I could. I would only add to his point re MOD's "previous". When I was serving, much was made within the RAF of the "independence" of the RAF Flight Safety System of the CoC. The Inspector of Flight Safety himself later discovered the hollowness of that claim when his various "Arts" were disappeared by certain RAF VSOs. The MOD, and in particular certain RAF VSOs, has form in subverting UK Military Air Safety. Only by making Military Air Regulation and Investigation truly independent of the MOD and of each other can the weary journey of retrieving UK Military Airworthiness be started out upon.

[alfred_the_great]

Only by making Military Air Regulation and Investigation truly independent of the MOD and of each other can the weary journey of retrieving UK Military Airworthiness be started out upon.


How? Would you be happy for entirely non-mil pilots and engineers to be investigating the military?

[The Old Fat One]

The CAA and AAIB haven't lied in official reports, to bereaved families, Coroners or other legal authorities.

That's a rather sweeping statement, don't you think? There are documented cases of aviation authorities in other parts of the planet "fudging" (for want of a better word) accident reports...I say old fellow, are we immune to this behaviour simply because we are British???

Come to think of it, don't us Brits and Germans still legally disagree over the cause of a certain well-known aviation accident at Munich??

Apart from the fact there is no way on Earth you can know whether or not your sweeping statement is true, Fortissmo raised an objective point of logic, and you answered it with a (highly disputable) subjective empirical statement. Frankly, that's academically woeful.

Fortissimo, tuc has replied on my behalf and better than I could.

Blimey, you must hold yourself to extremely low standards of debate.

[tucumseh]

TOFO

OK. 'To my knowledge, in UK military deaths'. Satisfied? In fact, it is the AAIB who have consistently told the truth.

MoD lied. Fact. Named and published, and passed MoD scrutiny and clearance. Still waiting for a complaint or challenge.

Raise your standards and publish yourself.

[roving]

The former Station C.O. of RAF Kuala Lumpur in the late 1960's when chairing a UK/US Military Symposium on the role of the Royal Air Force in the Malaysian Emergency, said in terms, that it was always assumed that the not infrequent crashes of Valettas over the jungle killing all on board were as a result of pilot error until three air loaders survived a crash and described how the pilot had told them to strap themselves into their seats and brace. Subsequent detailed examination of one of the engines revealed it had oversped.

Makes one wonder what proportion of the very many fatal crashes of Royal Air Force aircraft in the 1950's and 1960's were wrongly blamed on pilot error.

[Chugalug2]

ATG:-
How? Would you be happy for entirely non-mil pilots and engineers to be investigating the military?
No, I wouldn't. Nobody has suggested that an independent Investigator (or Regulator come to that) should be entirely non-military). It was not JOs or SOs that perpetrated this mess, it was RAF VSOs who subverted the Air Safety System, and RAF VSOs who have covered it up since. Of course military and civilian personnel would be involved in both functions, but they would be led by civilians outwith the MOD.

Now I'm sure that there are many holes to pick in that and the final form needs crafting by somebody knowledgeable and respected enough to be accepted by all. He'll have an impossible job, but it won't be because of the likes of me or others who fight for military airworthiness reform, but because of the hubris of a leadership that brings shame on a Service that should be instead solely concerned with celebrating its centenary.

[Chugalug2]

TOFO, the ball boy! Play the bloody ball! Your diatribe is an example of the standard of debate that you call for?

In every airworthiness related fatal accident thread on this forum, when the language got personal we knew we were getting somewhere. So what is about to be unearthed now I wonder?

[roving]

There is a simple solution to ensuring that these fatal accident reports bear scrutiny.

The SoS asks the Lord Chancellor to appoint a panel of recently retired (they retire at 70) High Court Judges to Chair the BOI. He sits with military assessors and has power to call evidence from any quarter. To ensure that the evidence of witnesses is properly presented and examined, from a panel of suitably experienced Counsel, one is appointed to assist the Board. A full transcript of the evidence is taken.

If VSOs wish to contribute to the inquiry they appear before the Board to set-out their case.

Once the report is signed off by the chairman, it cannot be added to or subtracted from.

[tucumseh]

Roving.

Well said.

A slight variation of this was suggested some years ago, and rejected by MoD. (Surprise). It was also suggested that a Senior AAIB Inspector be a permanent member of the Panel, and his boss sign off the report. This, because MoD has serially misrepresented AAIB evidence. For example, Mull of Kintyre, when the Inspector finally had his say and exposed the truth to Lord Philip in early 2011.

Another reason for reform is that current regulations offer Servicemen who might be criticised the right of reply before the report is published. But, this does not extend to civilians. For example, Sea King ASaC Mk7 (2003), where MoD identified civilian staff to families and blamed them for the (Board's) main contributory factor, despite photographic and written evidence that cleared them. MoD still denies the existence of this evidence (or perhaps thinks it forged - it won't say).

In this XX177 case, a judge familiar with investigative procedures would have immediately exposed MoD's lies about when it was informed of the risk associated with over-tightening the nut. That is, he would have listened to first-hand witness evidence.

[Just This Once...]

I would remove the ‘Service Interest’ test from prosecution decisions, leaving ‘Public Interest’ as the sole test used by the SPA.

A small change in words that would a dramatic effect on those in the most senior of positions.

[Lordflasheart]

Court 1, 11.00 am. Friday 23rd Feb, before The Honourable Mrs Justice Carr DBE

I wonder if she's been reading PPRuNe ?

What would be considered a respectable time interval before the public found that MBA had been guaranteed security of tenure for another few years at Chalgrove ? Or not, as the case may be - "We lied" as they say in all the best conspiracy movies.
Or more politely - "Terrrribly sorry old boy, the Minister was not minded to be persuaded, nothing we could do, it's out of our hands now."

..........

[Basil]

Red Arrows death: Ejection seat firm fined £1.1m - BBC News (http://www.bbc.co.uk/news/uk-england-lincolnshire-43171049)
MB fined £1.1m

[roving]

As appears from this fine in 2016, the fine in the current case was at the low end.

Star Wars film maker fined £1.6 million for injuring Harrison Ford | Media centre - HSE (http://press.hse.gov.uk/2016/star-wars-film-maker-fined-1-6-million-for-injuring-harrison-ford/)

[Evalu8ter]

Although on a different scale, this appears to be analogous to the Apollo 1 inquest. North American Aviation had a mountain of documentation that showed NASA were, at least, equally culpable for some of the decisions and processes that led to the fire, not least the high pressure 100% oxygen requirement and inward opening, non-jettisonable, hatch. Lee Atwood, CEO of NAA, effectively made the decision to take it on the chin as proving NASA's part could kill-off Apollo, and would only serve to hurt longer term prospects. He paid the fine, fired a couple of prominent people (Harrison Storms included) and then put it behind them. It worked as well; North American Rockwell got the contract to design and build the Shuttle a few years later. To me, this reads as MB rolling over for the sake of an important reference customer, and not wishing to point the finger at VSOs / high grade CS who will, in time, be making decisions that could effect them, or, worse, start recommending other manufacturers when asked for advice by 3rd parties.

[Chugalug2]

I understand the analogy you make, Evalu8tor, but only up to a point. Other than making money (the point of any business), the whole ethos of MBL is about saving aircrew lives. How does leaving a UK Military Air Safety System still dysfunctional, and likely to remain so thanks to the cover up, help save aircrew lives? Somebody, somewhere, has to decide that this is their problem and to set about solving it. That person is clearly not the MBL CEO, nor any of the other worthies who have failed military aircrew thus far.

[tucumseh]

Well said, both Evaluator and Chug.

Well, for the first time we now know the details of the charge. The 'quality of design' charge was, indeed, dropped in November. (Everyone was misled by HSE referring back to this allegation at the sentencing hearing, despite having dropped the charge. The judge should have jumped on them). The media continues its sensationalist reporting, referring to this allegation; but not the reason it was dropped - MoD's admitted liability.

So, £1.1M for not providing a technical bulletin in 1990, warning of basic engineering practice that is set down in MoD APs and trade training since (to my personal knowledge) 1970. The trade training AP was provided in evidence. (AP3279, Standard Technical Notes, Section 1, Ch. 4, Para 30 - Usage of Stiffnuts). I'd naturally deviate to this, if only because it uses the correct term for the nut.

The bottom line here is: MoD has claimed that between first adoption of the Scissor/Drogue Shackle design in the late 40s/early 50s, and Flt Lt Cunningham's death in 2011, it knew nothing about the most basic design feature of the parachute release mechanism, or how to maintain it. This is clearly a lie, and I challenge any qualified seat maintainer to put his hand on a bible and say he didn't understand the mechanism. I also challenge ANY maintainer to take a look at the assembly drawing and the paragraph in the AP describing operation, and claim he doesn't know that the nut should not be over-tightened. This is first-month apprenticeship stuff folks. Its akin to an aspiring pilot's first theory of flight lecture, and the bit about lift.

Yes, M-B rolled over, and we need to understand why. More importantly, we need reassurance that the MoD system that was deliberately run down will be resurrected. The MAA have had 8 years, and are still in the starting blocks. And what aircraft are the former seat/Hawk staff now looking after?

[oldmansquipper]

Well said, both Evaluator and Chug.

Well, for the first time we now know the details of the charge. The 'quality of design' charge was, indeed, dropped in November. (Everyone was misled by HSE referring back to this allegation at the sentencing hearing, despite having dropped the charge. The judge should have jumped on them). The media continues its sensationalist reporting, referring to this allegation; but not the reason it was dropped - MoD's admitted liability.

So, £1.1M for not providing a technical bulletin in 1990, warning of basic engineering practice that is set down in MoD APs and trade training since (to my personal knowledge) 1970. The trade training AP was provided in evidence. (AP3279, Standard Technical Notes, Section 1, Ch. 4, Para 30 - Usage of Stiffnuts). I'd naturally deviate to this, if only because it uses the correct term for the nut.

The bottom line here is: MoD has claimed that between first adoption of the Scissor/Drogue Shackle design in the late 40s/early 50s, and Flt Lt Cunningham's death in 2011, it knew nothing about the most basic design feature of the parachute release mechanism, or how to maintain it. This is clearly a lie, and I challenge any qualified seat maintainer to put his hand on a bible and say he didn't understand the mechanism. I also challenge ANY maintainer to take a look at the assembly drawing and the paragraph in the AP describing operation, and claim he doesn't know that the nut should not be over-tightened. This is first-month apprenticeship stuff folks. Its akin to an aspiring pilot's first theory of flight lecture, and the bit about lift.

Yes, M-B rolled over, and we need to understand why. More importantly, we need reassurance that the MoD system that was deliberately run down will be resurrected. The MAA have had 8 years, and are still in the starting blocks. And what aircraft are the former seat/Hawk staff now looking after?



Reassurance required Indeed, however, I personally doubt it will be forthcoming.

The seat Support Authority was headed up by a Supply Branch Wing Cdr as early as the 90s (during the charge to cut costs), Nothing wrong with Supply branch officers of course but you get my point? Airworthiness responsibility was being driven down to low levels (Flt Lt) even then.

Its (seat office) responsibility is probably now "Chairs, Arm, domestic, UAV pilots for the use of"

[tucumseh]

The seat Support Authority was headed up by a Supply Branch Wing Cdr as early as the 90s (during the charge to cut costs)

That was as a result of DGSM (an AVM) issuing an edict that, henceforth, any admin staff (Service or civilian) were to be regarded a senior to any engineer. A young lady supplier, 3 grades my junior, was appointed as my line manager. Much to her horror. Sylvia, I hope you are well. We won that battle, but the ethos remains.

[oldmansquipper]

That was as a result of DGSM (an AVM) issuing an edict that, henceforth, any admin staff (Service or civilian) were to be regarded a senior to any engineer. A young lady supplier, 3 grades my junior, was appointed as my line manager. Much to her horror. Sylvia, I hope you are well. We won that battle, but the ethos remains.

Yes, after retirement I recall visiting an ex Flt Lt Eng boss of mine who was in an HQ post somewhere in Southern England. He was a Gp Capt by that time, and was sharing a very small office with another Gp Capt. Their 'line manager' was a lady 'CS' a couple of grades lower than them. She had her own office.

Hey ho, I expect it was cost effective and there were probably too many Gp Capts anyway.....

[Evalu8ter]

Chug,
I agree. I guess that MB feel that if they pressed the issue and MoD copped a load of blame, their business could suffer. If they went out of business, would their rivals carry the same underlying ethos into the future? There are several rotten apples in the MoD/CS - many still hiding behind pernicious rules and intimidatory practices....

[tucumseh]

Judge's remarks make for 17 pages of interesting reading. Time after time she rejects HSE's position. In fact, if you knew nothing else about the case, at page 9 you'd be thinking, she's recognised this charge is a crock and is going to dismiss. But the guilty plea gave her nowhere to go.

One key issue. Examples of aircraft manufacturers applying their own standards to the Martin-Baker assembly instructions, which practically assured the risk of jamming would occur eventually. If M-B are at fault at all, it is in not telling them all to F*** right off. Instead, it seems they tried to satisfy different regulations in different countries, which goes a long way to explaining why some had certain instructions, and others not.

But what is omitted is the boundary of responsibility between M-B and BAeS for issuing in-situ servicing instructions; and the fact that neither had responsibility in 1990. HSE and MoD knew this but (surprise) omitted it.

She does confirm she received the evidence of all this, but did not read it. Instead, sending it to HSE for comment. Not that the prosecution would write back and admit they'd ran an investigation worthy of Fred Karno's Army.

[Chugalug2]

I see no reason why they should go out of business, Evalu8tor. They have a unique UK product and expertise. The MOD won't cop a load of blame anyway. If HSE pointed the finger at them, yet more SO/JO goats would be offered up for sacrifice. That is no reason for MB to plead guilty and some other reason must be behind it. I am inclined to the Chalgrove theory offered by others. Blackmail is an ugly word, this whole affair is an ugly business but just a normal day at the office for MOD. All the more reason to extricate UK Military Air Regulation and Accident Investigation from its maw.

omq:-
I expect it was cost effective

I doubt you do OMQ. That is the sorry irony of "Savings at the Cost of Safety", any savings were very short lived and the cost in blood and treasure continues relentlessly, unless and until airworthiness and accident investigation reform occurs.

[BossEyed]

Judge's remarks make for 17 pages of interesting reading.

Are they online?

[airsound]

I can't find the judge's comments online - but this link will take you to a digitised copy of the paper version that I received at Lincoln Crown Court yesterday. (Thanks to tuc)
https://we.tl/XXuk31tYZM

airsound

[roving]

Thanks airsound. I assume in due course the transcript will appear on the Judiciary website.

https://www.judiciary.gov.uk

I see the Judge accepted the Defence's proposition that MB was entitled to assume that RAF Engineers would use common sense, which seemingly they did not.

[BossEyed]

Thanks, airsound.

[oldmansquipper]

I see no reason why they should go out of business, Evalu8tor. They have a unique UK product and expertise. The MOD won't cop a load of blame anyway. If HSE pointed the finger at them, yet more SO/JO goats would be offered up for sacrifice. That is no reason for MB to plead guilty and some other reason must be behind it. I am inclined to the Chalgrove theory offered by others. Blackmail is an ugly word, this whole affair is an ugly business but just a normal day at the office for MOD. All the more reason to extricate UK Military Air Regulation and Accident Investigation from its maw.




I doubt you do OMQ. That is the sorry irony of "Savings at the Cost of Safety", any savings were very short lived and the cost in blood and treasure continues relentlessly, unless and until airworthiness and accident investigation reform occurs.

I totally agree, chug. My comment was 'T.I.C' of course.

But, in the long run, you get what you pay for I guess. So sad so many lives have been lost needlessly during that run.

[Heathrow Harry]

well on Monday morning I presume all we'll hear is vast sigh of relief from inside the MoD and the hum of shredders...... and box loads of documents heading for Kew with "Do Not Open for 50 years" stencilled on the outside

MB will sign a cheque, tell everyone to say nothing and "slightly" increase prices for 2019 & 2020

A classic British outcome............ but hardly "justice"

[dragartist]

Looking at the photos used by the BBC the RAF could go with some new spanners, all the grollied up bolt heads. I wonder if they have to share one multi purpose adjustable between the squadrons.
Absolute crazy out come.
Cunningham Dad summed it up nicely with his comment over lack of RAF in Court.

[tucumseh]

Harry

They'll try, but unfortunately one aircraft project team released under FoI the information that another tried to conceal, revealing MoD's guilt. Classic MoD. The HSE confirmed they had not seen it. Some would say they were then duty bound to report this to the judge. This report, and associated papers, proved that, even if M-B didn't send out a piece of paper in 1990, MoD knew of the precise risk in 1990 by another means, and in 1993, 1998......; because they'd consciously rejected the mitigation that would have eliminated it.

I do hope people here realise that a root cause of Flt Lt Cunningham's death was the same refusal to implement mandated regulations that was confirmed by Mr Haddon-Cave in 2009; which merely repeated the same warnings by the RAF Director of Flight Safety in 1992, 96, 97, 98....; and internal MoD audits from 1988.

[Heathrow Harry]

I know Tuc , I know... but they can bury this one and they will

And in 2-4 years we'll be on here again with another case with some poor sod dead or seriously injured because no-one will do something

Short of a PPrune reader becoming PM and instituting changes I can't see it changing

I have a recollection that Jim Callaghan had a list of things he'd come across all the way from his RNVR days that were acted upon (quietly) when he became PM in the mid-70's........................................

[oldmansquipper]

I know Tuc , I know... but they can bury this one and they will

And in 2-4 years we'll be on here again with another case with some poor sod dead or seriously injured because no-one will do something

Short of a PPrune reader becoming PM and instituting changes I can't see it changing

I have a recollection that Jim Callaghan had a list of things he'd come across all the way from his RNVR days that were acted upon (quietly) when he became PM in the mid-70's........................................


Tuc for PM?

we could, and probably will, do worse.

Personally, I hope and pray that this awful `airworthiness` saga can be resolved. with, , at the very least, those responsible being forced to account for their actions.

However, I suspect this will not happen and the MoD will probably disband itself before admitting its `mistakes`.

[Vendee]

In these days of contracting out, I wonder how much it would cost to get the CAA to oversee military airworthiness? Of course I do realise that this would never happen and the MOD is quite happy with its incestuous approach to independent oversight.

[Distant Voice]

Para 2 (page 1) of judge's statement,

"his seat was inadvertently ejected, something that is a recognised risk"

And that is why Martin Baker recommended the fitment of a shroud on the ejection handle, in order to mitigate that risk. But the RAF/MoD rejected a solution that had been applied for many years on earlier RAF seats, and still used world wide.

Some will say it was not liked, fine, so have it modified, which is precisely what is happening (may have happened) right now. Too late.

DV

[Could be the last?]

Notwithstanding the comments made on this thread ref MB and MOD and the way that this has evolved over the last 6 years - it is the interview given by Sean’s father to BFBS News that shows what a sorry state of affairs that we have found ourselves in. Obviously, there is both sadness and anger in how he describes what his family has gone through, but more damming is the fact that he states not a snr RAF Officer attended the court when the fine was given to MB. I appreciate that there will be politics and legal nuances associated with the proceedings but, if true, to not be represented at the court, presentationally is very poor.

https://www.forces.net/news/breaking-ejector-seat-company-fined-over-red-arrows-pilot-death

The news broadcast was watched on BFBS (not in the UK) due to bandwidth this is the closest I can get to the segment that was broadcast.

[oldmansquipper]

Notwithstanding the comments made on this thread ref MB and MOD and the way that this has evolved over the last 6 years - it is the interview given by Sean’s father to BFBS News that shows what a sorry state of affairs that we have found ourselves in. Obviously, there is both sadness and anger in how he describes what his family has gone through, but more damming is the fact that he states not a snr RAF Officer attended the court when the fine was given to MB. I appreciate that there will be politics and legal nuances associated with the proceedings but, if true, to not be represented at the court, presentationally is very poor.

Do you have link detail for the BFBS news please

[Distant Voice]

Para 2 of page 5 of Judge's statement.

This design is now an ”old” design. Since about 1984 MBAL has not designed any new seats with a mechanical scissor shackle. Rather it uses an improved gas-release shackle system, available for new aircraft and also for retro-fitting. The MOD contracted MBAL to carry out such retro-fitting on all in-service ejection seats, with the exception of the seats in the Hawk aircraft.

I will deal with the last issue first, a question that no one asked, why were RAF Hawk seats not modified?

The main thrust of this statement gives the impression that the MoD initiated a retro-fitting programme to replace "old" design shackles. We have no idea who fed the Judge with this information but we know, thanks to the 2002 QinetiQ report, that this is false. The QinetiQ report makes it clear that prior to a new jamming problem that occurred in 1998 there was no intention on the part of MoD to retrofit Tornado GR4 and F3 aircraft with the gas shackle. The only mods in the pipe line related to the replacement of the GQ1000 parachute with the GQ 5000. It was only when the problem occurred during a re-qualification trial for the new chute that MoD swung into action. It then took a further seven years before Tornado seats were modified.

The HSE was aware of the 2002 QinetiQ report and the chain of events leading up to the gas shackle fit in Tornado. However, they never brought this information to the attention of the judge and the court. Clearly, a major HSE failing.

DV

[4mastacker]

I heard Mr Cunningham's comments toward MOD and the RAF on BBC Radio Lincolnshire on Friday afternoon. Unfortunately I can't find the programme on their web-site. However, here's a link the to BBC news web-site which reports part of the family's statement.

Red Arrows death: Ejection seat firm fined £1.1m - BBC News (http://www.bbc.co.uk/news/uk-england-lincolnshire-43171049)

[dragartist]

http://www.bbc.co.uk/news/uk-england-lincolnshire-43171049

OMS, Same was reported by the BBC. Hope the link works.

You mentioned somewhere above about a supply Officer being HOB back in DGSM days. Yes but the Gp Capt was suitably qualified. The supply Officer never had any LoD other than for counting the beans. When the IPT was set up in 1999/2000 things were reasonably managed. Three years later the Gp Capt PVRd.
Then we saw the two Civi Guys come into play. I would not let either one fix my bike. Tech Pubs in Brown Street shut up shop leaving no one with the skills to manage the publications.
Skills have been eroded on the front line. I think Tuc mentions how it was second nature not to overtighten the mechanism, assuming the tradesman knew how the mechanism was supposed to operate. Not sure what the standard of trade training notes are today. I still have some of my dads from 50s through 70s. For these applications thin headed shear bolts were the order of the day with pinned castlated nuts.
For Designers the SBAC published guidance books on everything from pipe fittings to riveting. Never saw these updated since 70s.
How do folks learn these days?

HH can you tell Mr Fox about Jim. The impression is that all Labour MPs of the era were Soviet Sympathisers.

[dervish]

DV

Clearly, a major HSE failing.

More like perverting course of justice if they held back evidence.

[RetiredBA/BY]

Para 2 (page 1) of judge's statement,

"his seat was inadvertently ejected, something that is a recognised risk"

And that is why Martin Baker recommended the fitment of a shroud on the ejection handle, in order to mitigate that risk. But the RAF/MoD rejected a solution that had been applied for many years on earlier RAF seats, and still used world wide.

Some will say it was not liked, fine, so have it modified, which is precisely what is happening (may have happened) right now. Too late.

DV
A recognised risk?
So how many such inadvertent ejections have there been?

[BEagle]

I can think of 2, perhaps 3:

1. The Harrier pilot who it seems stood on his seat firing handle at Yeovilton but hadn't replaced the pins. Fatal accident.

2. The Fighter Controller who managed to bang out of a Hawk over the North Sea. Fished out safe and sound. I watched the Hawk landing at Wattisham - it looked very odd with the pole sticking out of the back cockpit.

3. Details rather hazy, but many years earlier, turbulence caused a Canberra seat to drop with sufficient force to fire the main gun. Sudden ejection came as a surprise to the occupant, who managed to complete the manual separation procedure despite the surprise?

[tucumseh]

A recognised risk?
So how many such inadvertent ejections have there been?

To place her words in context, she also criticised poor training, and the SI report is excellent in that respect. The risk was indeed low, but increased to a significant degree when MoD diluted training and weakened other defences in depth, without making compensatory provision. I was but a lad when the Service HQ posts responsible for identify these things and making provision were chopped. Numerous official reports have criticised this move, I suppose the most notable being in 1996 as it was direct to PUS.

[Fortissimo]

The Fighter Controller who managed to bang out of a Hawk over the North Sea. Fished out safe and sound. I watched the Hawk landing at Wattisham - it looked very odd with the pole sticking out of the back cockpit.



By coincidence I was airborne on the same exercise and heard the MAYDAY call, including the amusing description of water entry, disappearance of survivor, followed by reappearance a few seconds later.


The seat occupant has always said the seat just fired without any warning and that his hands were nowhere near the handle. There was a lot of chat at the time that suggested the close-aboard cross turn may have had a bearing on events and that, if the seat was ever found, the handle would be fully extended. Only one man knows the truth and we must take him at his word but I believe that, other than some of the early top latch failures, it is the only case of an inadvertent ejection that did not involve some form of physical interaction with the system.


Back to the thread...

[glad rag]

I can think of 2, perhaps 3:

1. The Harrier pilot who it seems stood on his seat firing handle at Yeovilton but hadn't replaced the pins. Fatal accident.

2. The Fighter Controller who managed to bang out of a Hawk over the North Sea. Fished out safe and sound. I watched the Hawk landing at Wattisham - it looked very odd with the pole sticking out of the back cockpit.

3. Details rather hazy, but many years earlier, turbulence caused a Canberra seat to drop with sufficient force to fire the main gun. Sudden ejection came as a surprise to the occupant, who managed to complete the manual separation procedure despite the surprise?

Harrier pilot dragged out through canopy.

:(

[BossEyed]

As glad rag says, the Taylor Scott tragedy and there was also an event in the late 80s or early 90s at Boscombe when a Tornado seat went through the hangar roof, apparently severing a gas pipe as it went. A near miss for the maintainer that day, I believe.

[Distant Voice]

A recognised risk?
So how many such inadvertent ejections have there been?

Risk is the possibility of harm because of a hazard, which can, and was mitigated against. Martin Baker made it clear in their response to the coroner's Regulation 28 report on 17th April 2014 that misrouted strapping is "well known risk". The risk was effectively managed by a number of factors, the main one being shrouds over seat firing handles.

The MoD has a reactive, rather than a proactive approach to risk assessment, it is only regarded as a risk if an incident has occurred.

DV

[oldmansquipper]

Hi David

I have emailed you (at length)

Please let me know when you get it

G

Sorry Dragartist . Fat finger syndrome wrong bloke !!!

[dragartist]

Several screens back there was discussion about there not being a valid safety case for the seat in place at the time of the incident.
Has action been taken to put one in place now?
Surely the judge would have picked up on this.
I remember back in the early 2000s on the S&AD IPT we had recruited a Safety / Risk Manager. All very vogue and in keeping with what was going on at the time. Lots of pleasant noise over being pro active rather than re active. A number of HAZOPS had been ran involving all stakeholders.
That noise soon turned into hollow noise with the Safety Manager incumbent moving sideways to become the Business Manager. Another thing that becme vogue at the time! Almost like flavour of the month across the whole of the SMG early days of DE&S. Looking after Service Level Agreements and the like, rolling out many of the IT management systems such as Ballanced Scorcards, massaging Business Cases for Projects through the system.
So what happened after this. Was there ever a Safety Manager, did the Project Manager ever get round to preparing a Cassandra Hazard Log, did they ever hold a HAZOPS. The 2002 QinetiQ Report surely would have been referenced in this and probably also referenced in the RTS and supporting Certificates.
Perhaps the chap responsible at the time was busy trying to make himself look good in realising all the savings being demanded or lining himself up for a position in Industry when everything was contracted outlock stock and barrel.

[tucumseh]

Dragartist

The 2002 report references 39 other reports and documents. As of last month, MoD claims not to have any of them. And in 2014 MoD and Minister Philip Dunne claimed to have no knowledge of the 2002 report (and by extension, the 39 references). If there is a hazard log, safety case, etc, then MoD is admitting they are not referenced in it. Given the evidence relates to the Tolerable and ALARP statement, the Safety Case and RTS cannot therefore be valid in critical areas.

Readers may recall the basis of the charge against M-B was that it did not provide information to MoD in 1990 about the risk of over-tightening the Drogue Shackle Nut. Yesterday, the Health and Safety Executive confirmed, in writing, that it was well aware of witness evidence that MoD DID have the information, before 1990, and also that the modification to eliminate the risk was turned down by MoD in or around 1990. And on various occasions since. That, it did not think this exculpatory evidence 'relevant' enough to pass to the judge. This admission means perjury at the Inquest in 2014 is a distinct possibility, as it was claimed then that MoD had no knowledge whatsoever of the risk.

The Service Inquiry said the information could not be found, yet referenced various reports that set it out (stating they were 'non germane'). Where did it get that information, given MoD claimed not to have it? This is not the first time a Service Inquiry/BoI has cited documents that other parts of MoD have flatly denied the existence of. Chinook ZD576 and Sea King ASaC mid-air are the most obvious ones I can think of.

[airpolice]

The bottom line is that the MoD/RAF got away with allowing one of their own to die.

Now it seems to be nobody's fault, and so, nobody is to be punished. The lessons to be learned, were already known.

MB get to pay a fine, not one person is in the frame.

The only guy to suffer is Flt. Lt. Cunningham.


Nothing to see here, move along.... until the next time.

[Engines]

Tuc, Others,

I might be able to shed some light on the MoD's inability to locate documents. I apologise in advance if this post has a flavour of 'the good old days' about it - it's not aimed at criticising the people now trying to do their best in the MoD. I also apologise for boring some of you.

A long time ago in a universe far away, the business of MoD departments (and commands) was conducted on paper using things called files, or in Navy parlance, 'packs'. If a letter (or signal, or other communication) came in, the registry would put it in the appropriate pack for you. They did this using a 'pack index', which everybody in the department used. They then sent you the pack, with the letter (or signal) highlighted as a numbered 'New Paper'. Here's a really important thing. The packs had a series of numbered 'minute sheets' in the front, in which you recorded EVERYTHING you did with that pack. If you just commented on a letter, you minuted it. If you wrote a Loose Minute, that was minuted. If you wrote a letter, you minuted it. If you made a decision, you minuted it. If you wanted the issue cross referenced to another pack, you minuted it. Registry minuted every addition to and withdrawal from the pack. Every minute was numbered and dated.

A final really important thing. If any pack dealt directly with airworthiness evidence or decisions, it was labelled as 'Airworthiness File' or 'Airworthiness Critical'. This applied extra controls on the packs, including secure stowages, more frequent reviews, more senior signatory levels, etc. The whole point of all this was to ensure that the decisions and instructions issued by the staffs were recorded in an auditable trail. It also also ensured that they could be found when required. It also made sure that papers weren't inadvertently destroyed.

Sounds cumbersome, doesn't it? You'd expect this system to be slow and unable to react quickly. You'd also expect that it would involve hundreds of admin types shuffling paper. Dead wrong. A properly run Registry could get packs to you in minutes if required, on top of the daily 'drops' they carried out. Or you could go down there and sign the pack out. Emails were easy to control, if you just used the same numbering system for your computer files as the 'pack index' used.

Why have I bored you with this stuff? Because the MoD lost almost all of its control over airworthiness data as it entered the 'paperless' age. In my direct experience, few departments imposed a central numbering system over the new digital file folders being created by the thousand at hundreds of terminals. Again in my direct experience, one PT had no less than FOUR separate file folders, each purporting to be 'the' list of applicable Service Modifications. Simply put, the PTs no longer had an accurate record of where much of their airworthiness and technical data was. The Registries had been replaced with (larger) Business Management Teams and the task of file upkeep was transferred to the technical desk officers. Some did it diligently. Sadly, many didn't. Again, direct experience - I was asked to take over a complex avionics upgrade project - on calling for the files I was handed twelve inches of loose papers, which I was told represented the record of one year's work.

Paper files were now used to do no more than hold a copy of emails and letters - if the desk officers could be a***d to print the copies. Often, they couldn't. Minute sheets had fallen out of use, so reconstructing the history of a technical issue was now almost impossible. If you thought it couldn't get any worse, think again. In around 2009 new instructions were issued that henceforth, no 'weeding' or cross referencing of files was allowed, nor were papers to be moved from one file to another. The instruction explicitly said that the aim was to 'reduce time wasted in managing obsolete paper files'. Hundreds of files went off to 'archive', meaning that it was now impossible to find out what data was there.

I'm sorry, once again, for boring you with this, but it's germane to one of the most astonishing feature of this tragic accident. (to me, anyway). I continue to be amazed that anyone would have approved the issue of a Technical Instruction that called for the ejection seat drogue shackle to be dismantled every 50 flying hours, and then for this work to be carried out at first line. So, when I first read the SI report, I looked forward to an explanation. What I found astonished me. There was NO audit trail recording how the RTI came to be applied to the seat. NO entries in the 'Cassandra' hazard log. NO record of key decisions. NO explanation of why 22 Group decided to press for the adoption of an RTI that clearly posed a serious safety risk. NO record of who signed off the RTI without having checked it against the appropriate Safety Case. It's my considered view that had RTI/59D been properly staffed, recorded in the Hazard Log, reviewed by the right bunch of people (that would have been a Local Technical Committee, until they were disbanded), this accident might well have been avoided. Someone, somewhere would have stuck up their hand and asked whether RAFAT first line personnel were the right people to start taking ejection seats apart every 50 hours.

The SI report concludes with a series of recommendations, many of which say that PTs should 'ensure that they have a robust and audible method of tracking, reviewing and managing airworthiness decisons'. Tuc would say (correctly) that this is no more than 'comply with mandated instructions'. I'd have gone with a more direct approach, involving a number of Anglo-Saxon words.

If you fly a UK military aircraft right now you need to be concerned. If you're working in a PT and you can't lay your hands on airworthiness related data, you need to be worried. If you aren't recording what you are doing, and making sure that those records are being kept, you need to be REALLY worried. If you work in a PT and don't know what 'airworthiness related data' is, or where it's kept, you need to think about a career change.

Best Regards as ever to all those doing their best under difficult circumstances,

Engines

[airpolice]

Engines, thank you for a comprehensive explanation of exactly where the wheel came off.

Can you explain why anyone, apart from the people sitting on the bang seats, should be worried?

Under what circumstances would anyone be in line for any kind of sanction or punishment?

I mean, really what would it take? People have died and still it's nobody's fault.

Why would you think they are going to get caught? Found out, yes, but caught? I don't see it.

[tucumseh]

(that would have been a Local Technical Committee, until they were disbanded)Key passage. The people who chaired LTCs were Technical Agencies, one of the most carefully controlled appointments in the airworthiness world. The most senior TA in any discipline (let's say, avionics, a world I'm familiar with) chaired the HQ Radio Mods Committee. He always had a deputy, because as a TA himself he would be submitting modifications and was not permitted to self-certify. These committees were themselves served by central registries. In this case, in the Directorate of Military Aircraft Projects. It was closed down in early 1993, to coincide with disbanding of the HQMC. Its voluminous records, which the very competent ladies could, as Engines says, access immediately, for any part of the history of the equipment or aircraft, were mostly destroyed, and some randomly archived. Not one TA knew the registry was to close until we turned up one day and it was empty.

I'll be kind here. This is why the Service Inquiry couldn't find the Safety Case Report or the evidence that MoD knew in 1990 of the mod that would eliminate the shackle pinching risk. But what it was also saying was that no one in the seat PT or aircraft PTs using Mk10 seat had any clue either. That, I can't believe.

Even if I extend my kindness, as soon as the 2002 report was released last month, it was incumbent upon MoD to immediately inform both HSE and judiciary that it had now uncovered the evidence (a) proving the SI wrong, (b) proving the Inquest had been misled, and (c) casting considerable doubt of the safety of the allegations made against M-B.

And we get back to the question - so why did M-B plead guilty to an easily defended charge? Not wanting to upset MoD simply doesn't cut it. I wonder what the MAA are thinking. It must be patently obvious that this case has set their work back 20 years or more. And given they haven't made much progress in 8 years, that's pretty serious.

[Engines]

Airpolice,

Good questions. Perhaps I can offer a partial answer. In around 2010, the MoD issued new security regulations. I was working on a PT, and was required to undergo the 'on line' training. I was amazed to find out that the new guidance for classifying information included 'protecting the reputation of the Government or the Department from damage'. I queried this, thinking that perhaps the MoD had just bought some generic 'data security' training package which also covered civilian organisations. Nope, I was told in no uncertain terms that classification of data would now be driven (in part) by whether it might damage the PT's (or the Government's) reputation.

Of course, this actually meant the PT Leader's reputation, or that of his superiors, including VSOs. As a contractor, I had NO reputation to protect. Nor did the rank and file desk officers. So, when you talk about people actually being held to account, the system has closed ranks over the past few years. Not exactly 'open government' is it?

My approach to the issue is not always 'hang the swines' - unless they are the senior people who should d**n well carry the can. The best way is to make sure that the systems, processes and training of the people in the organisation are up to the job they've been given to do. In this case, know how important keeping full, organised and available records is, and making sure that they do their part to make sure it happens. To answer you directly, I was hoping that where people are discharging professional responsibilities, they will be worried if they find out that they're not doing their job properly. I admit to being an optimist here. The central problem is that the rank and file in the MoD are being managed and driven to 'just get the job done', not 'do the job properly'. By the way, 'doing the job properly' does not have to mean that it takes longer.

Best regards as ever to all those doing the job properly,

Engines

[Chugalug2]

Engines, excellent posts, Sir! You describe in detail the extent of the dysfunctional mess that is present day UK Military Air Safety. Tuc has described before how files and records were "disappeared" overnight. That is why Sean Cunningham died, because that which would have kept his seat, his aircraft, and every other system and aircraft in the RAF, the FAA, and the AAC airworthy went through the shredder or was simply buried. Oh, and just to make certain that there would be no chance of saving the day, anyone who resisted this anarchy, who sort to enforce the regulations in defiance of orders to suborn the system, were summarily got rid of in place of unskilled, untrained, non-engineers.

That is what is being covered up. That is why the MAA is both unable and unwilling to expose that subversion, and why it cannot start out on the urgent reform that is necessary. That is why UK Military Air Regulation and Air Accident Investigation must be made independent of the MOD and of each other. As Engines says;

If you fly a UK military aircraft right now you need to be concerned.

I couldn't agree more!

[RetiredBA/BY]

Engines, excellent posts, Sir! You describe in detail the extent of the dysfunctional mess that is present day UK Military Air Safety. Tuc has described before how files and records were "disappeared" overnight. That is why Sean Cunningham died, because that which would have kept his seat, his aircraft, and every other system and aircraft in the RAF, the FAA, and the AAC airworthy went through the shredder or was simply buried. Oh, and just to make certain that there would be no chance of saving the day, anyone who resisted this anarchy, who sort to enforce the regulations in defiance of orders to suborn the system, were summarily got rid of in place of unskilled, untrained, non-engineers.

That is what is being covered up. That is why the MAA is both unable and unwilling to expose that subversion, and why it cannot start out on the urgent reform that is necessary. That is why UK Military Air Regulation and Air Accident Investigation must be made independent of the MOD and of each other. As Engines says;



I couldn't agree more!
I am not an engineer by training, just a pilot, civil and ex military. I find it hard to believe that the shackle would need to be dismantled every 50 hours, (as “engines” stated) at any line stage. Just what might be the purpose of such a procedure, as the shackle is hardly subject to any wear or material degradation in normal use. M.B. or MOD initiated ? Or have I missed something?

[Engines]

Airpolice, Tuc, Chug, Others,

Sorry, my bad here - my sincere apologies. I missed out a key part of the problem that is also relevant to the issue of missing records of meetings.

It's now very rare for meetings within the MoD to be minuted, or otherwise recorded in any way. I spent around two years in a couple of MoD departments and in both areas, the only time meetings were minuted was when I stepped forward and did it. It was vanishingly rare for a desk officer or civil servant to take minutes. Lest casual readers think that this is a huge waste of time and effort that should be spent better on 'the real job', it's vital if you're going to record decisions that have an airworthiness impact. And it doesn't have to take long. It's easy to prepare a blank set of minutes built around the agenda, then concisely record the decisions and actions placed in the appropriate boxes. I usually aimed to get the 'RODs' (Record of Decisions) out within 48 hours of any meeting.

In one of the areas I worked in, I went so far as to prepare a Powerpoint brief on 'how to hold a meeting', with examples of what a set of RODs needed to look like. I found myself giving the brief to departmental deputy heads.

This is another area where I don't see a malicious 'cover up' so much as a basic failure to manage and record the work required to safely procure and/or support complex air equipment. Again, I blame the bosses - they are the people who can set the standards, explain clearly what they want and see that it gets done. Honestly, these days, many of them have never attended a minuted meeting.

The more I think of it, the more I see this as the reason that the Cunningham SI were unable to find any records of the meetings associated with the RTI. It's probable that the meetings were simply never recorded. As Tuc so ably points out, this is a problem that never arose with LTCs. These were formal, highly structured meetings that would never have dreamed of not issuing minutes, Indeed, most department heads I worked with would have played merry hell if they hadn't seen the regular LTC minutes coming across their desks.

The MAA should not have to tell people to minute their meetings. This should be 'ops normal' for any organisation dealing with airworthiness issues. It's absolutely basic, standard, uncontroversial stuff that should be happening, but isn't.

Best Regards as ever to those taking the minutes,

Engines

[airsound]

When the great ones depart at last for their dinner,
The secretary stays, getting thinner and thinner,
Wracking his brains to record and report
What he thinks they will think they ought to have thought.

from The Manual of Service Writing, JSP 101, if I remember correctly (quite a long time ago....)

airsound

[tucumseh]

RetiredBA/BY

The dismantling was deemed necessary by the Hawk Support Authority, to do some NDT crack detecting. It was NOT thought necessary by MoD's own Subject Matter Experts (1710 Sqn). The instruction was issued via RTI/Hawk/059. The regulations forbade an RTI if the Design Authorities (Martin-Baker and, in this case, especially BAeS) needed to be involved. As it was an RTI, the chances decreased considerably of the mandatory up-issue of the Safety Case. The Service Inquiry commented on the first bit, and lack of a valid Safety Case; but not the rogue RTI. It confirmed Martin-Baker were not involved in the RTI, which contains a number of basic errors/omissions which would have been picked up had the process described above, by Engines and myself, been in place. That is, MoD no longer lets Agency Contracts to have an independent party check and double-check such instructions. Pre-1993, this would have snagged the RTI straight away. (I'd like to think the TA would spot it, and snag it internally in the first place). You could write a book about this case.

[tucumseh]

Engines

Quite right. Next day was normal, 48 hours tops. A Local Technical Committee is, by definition, a safety meeting. Ex-committee decisions were routine. In fact, if run properly the LTC itself was just a summary of events over the past period, some signing of papers, the odd bit of new business that had cropped up in the last 24 hours, etc. The company had financial delegation to commit MoD funding without the TA's approval - to get things moving on a safety issue. This is a unique delegation, and because of it the company man was a company nominee, but an MoD appointment. Again, unique.

[Engines]

RetiredBA/BY,

I'd like to add a couple of points to Tuc's (customary) excellent reply.

As the SI report makes clear, the RTI (RTI/59) was developed in response to discovering a crack in an ejection seat top cross beam in July 2010. With assistance from MB and 1710 Naval Air Squadron (the latest incarnation of what was once the Naval Aircraft Materials Laboratory , the MoD's only dedicated material testing and NDT laboratory) it was determined that a visual inspection for cracking every 14 days was appropriate, and that the seat could safely be operated with a cracked beam. This was recommended to the Hawk Support Authority.

Things now get hazy due to the lack of meeting minutes , and indeed of almost any records of the decision trail. In early August, the Hawk SA, with the AES PT, produced RTI/59, which called up a full NDT inspection of the beam, requiring disassembly of the drogue shackle. From the SI report, it appears that a meeting took place later in August chaired by 22 Group, acting as the Aircraft Operating Authority (AOA). The SI report says that the AOA was 'not content to operate the aircraft with a cracked cross beam as the visual effect might undermine aircrew confidence in the system'. Four further iterations of RTI/59 took place between August and October 2010 (unusual), leading to a 50 hourly check with associated disturbance of the shackle. The SI report notes that this 50 hourly NDT check was kept in place even after 1710 NAS had provided assurance to the PT that a visual (non-dismantling) examination was adequate.

In my view, the PTs (Hawk and AES) didn't have to impose the full RTI/59 on the seat. 1710 and MB had told them a visual inspection was OK. It appears that it was 22 Group who demanded the full NDT inspection so as not to 'undermine aircrew confidence'. Even after further assurance from 1710, the full RTI was kept in place. So why did 22 Group get to call the shots? Why did the PTs go for a full NDT inspection and shackle dismantling? Did the PTs get 'told' what to do by their aircrew? We just don't know. No minutes or records. The MAA saw all this as an 'other' factor. I respectfully disagree, and consider the failure to properly consider all the safety implications of this RTI to be a 'contributory' factor. But that's just my view as retired engineer. Doesn't really change the price of fish.

Best regards as ever to all those doing the work,

Engines

[Exrigger]

Just wondering how these sample 1000 series Regulatory articles fit in with the references to process/procedures/responsibilities within the thread, although it is to be noted that there is a lot of use of the word should, which is defined in MAA-002 as:

Should is the permissive verb used in the AMC to allow a Regulated Entity the opportunity to consider alternative approaches in meeting the regulation; noting that any alternative approach must be approved by the MAA.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/562638/RA1013_Issue_3.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/547779/RA1014_Issue_5.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/620806/RA1015_Issue_7.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/460627/RA1016_Issue_2.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/562642/RA1021_Issue_3.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/593278/RA1023_Issue_4.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/584859/RA1024_Issue_6.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/384436/RA1130_Issue_3.pdf

[Vendee]

Side issue I know but in the RA's linked to by Exrigger, Why do they use the American spelling "Organization" rather than the English language "Organisation"?

[OmegaV6]

Side issue I know but in the RA's linked to by Exrigger, Why do they use the American spelling "Organization" rather than the English language "Organisation"?

Probably because, just like one of my Wing Commanders who, when asked the same question, was adamant that it was the "correct" spelling. He didn't have the functioning brain cell to notice that his version of documents produced on Word said "English - United States" in the bottom left-hand corner, and further had no idea you could actually change the default language to "English - United Kingdom".

Yet another reason that made me wonder how he ever attained such a rank .....

[Exrigger]

Vendee a further aside includes the use of authorize/authorization & Cannibalize/cannibalization to name some more and omegaV6's explanation is not far from the truth.

[POBJOY]

As I have no 'informed' knowledge of where the ejection seat cross beam is and why it should crack perhaps someone can educate me.
This whole sorry episode is so full of 'bean counter' servicing cost savings affecting what is a very technical piece of safety equipment, that the 'man in the street' would be astounded that the company (MOD RAF) have allowed the capability of such equipment to be affected by a person working on such equipment not to realise the purpose of a 'shackle' or how this 'simple' device should be assembled. This situation only confirms that the 'standards' required for working on such equipment are not fit for purpose or that the (MOD/RAF) see that this is a problem. As an ATC Staff Cadet on a Gliding School I used shackles all the time and have done so for many decades since. In certain cases it is quite possible to 'pinch' the open end and usually a spacer bar or precision bolt is used in cases where this would cause an 'ongoing' problem. A shackle is normally used where 'movement' of the connection is required, and I knew that as a Cadet. It is quite obvious that something that is 'dismantled' many more times than originally planned becomes a 'consumable' and therefore in a very special case such as an ejection seat the cost of a new connection seems paltry. That the RAF have allowed standards to be reduced to such a level is a national disgrace and its VSO's have done the service no favours by allowing this for many years. I would not have dreamt this could be the case years ago, but have just seen my old Air Cadet Gliding organisation destroyed by such a lamentable state of affairs. MB have dedicated their business to saving lives and produce a first rate product that is so much more than a 'bang seat'; however their customers must realise that this special piece of complex safety equipment needs proper care and servicing from suitably trained staff and anything less is negligent. The RAF have been negligent and no amount of carpet shuffling or letting MB take a hit can hide that.

[Engines]

Exrigger,

A quick scan of these RAs shows (at least to me) the limitations of trying to ensure (ore assure) airworthiness via regulation. This, of course, has been the MAA's main mission - to regulate absolutely everything so that all people have to do is 'comply with the regulations' to assure air safety'.

Unfortunately, at least in my experience, the level of 'air safety' or indeed airworthiness, an organisation achieves is not at all related to the amount of regulations it tries to obey. I once chaired a meeting where we aimed to take a 'first pass' at comparing RN and RAF aircraft operating and maintenance regulations. The RN guys came in with four or five books. I am not making the next bit up. The doors swung open, and our RAF colleagues pushed in a large four wheeled trolley loaded up with many tens of volumes. Note - these were the non aircraft specific regulations.

I don't want to belittle my light blue colleagues here. They worked to good standards, were keen and professional engineers. But, as we quickly found out, there were numerous examples of regulations in their own books that they didn't even know existed. many were pure dross, and could be easily ditched. (To their considerable credit, a very smart Gp Capt engineer did just that a couple of years later - I cherish a hope that the sight of the RN's slimline stack of books might have helped start that process).

The sort of problems I've been pointing out on this thread won't be solved by writing more regs. It will need a more basic appreciation of WHY things need to be done in certain ways, not WHAT the regs tell you. I don't think I ever referred to the RN or JSP regs for running files and packs, or holding meetings. I applied the principles I'd been taught, observed my superiors (good and bad), learned from them, and when I was ready, brought my own ideas into play.

Just my opinion (warning - opinions here) one of the best ways to help achieve airworthiness/air safety would be for MoD PT projects to be subjected to the sort of 'phase reviews' that BAE started doing a while back. Very experienced engineers would come in and subject your project to really close scrutiny over a period of some days. Your project could NOT proceed until you had the phase review pass certificate. It was people like this who knew what to look for.

Best regards as ever to the fine young engineers who are now doing the business for real,

Engines

[Engines]

Pobjoy,

Take a look at the SI report on the standards of servicing that were happening on the RAFAT ejections seats. Key issues found:

1. There was no 'Q' course to qualify RAFAT airmen to work on the Hawk. Babcock personnel did a 5 week course - the RAF declined to use this course.
2. The Hawk TMK1 Support policy Statement said that there was no requirement for pre-employment training for airmen before they worked on the RAFAT. The Support Authority were 'unsure' as to why this was the case.
3. Then gaps were made up by OJT carried out by SNCOs. Many of these had no qualifications as instructors, nor was there an approved syllabus.
4. As a result of the above, RAFAT engineers were maintaining Hawk aircraft without any compliant training.
5. RAFAT armourers had no access to a central training cell. They had to rely on OJT to be trained to work on the ejection seats. A number of the RAFAT armourers had no recent experience of working on ejection seat equipped aircraft. One had had no seat experience in the 6 years since his basic training.
6. The SI found evidence of signatory and supervisory malpractice.

I struggle to find reasonable words to express my thoughts on this lot, without appearing to be a permanently grumpy old retired engineer, I really do. Ejection seats can, will, and have killed, and in the RN they were always treated with severe respect. Armourers working on seats were properly trained, qualified, certified, checked, and and there was any dismantling of seat sub -assemblies required, the whole seat came out and went back to the seat shop. Taking seat shackles apart every 50 hours using as setup like this was just asking for trouble. The SI correctly notes it as a contributory factor.

In sum, I simply don't recognise what the SI report sets out as any form of professionally run fast jet maintenance operation. The tragedy is that NONE of this lot is now going to come out, MB having pled guilty.

This is one area where 'hang the guilty b******s' works for me.

Best regards as ever to those doing the best with what they have,

Engines

[superplum]

Well said Engines!

[Exrigger]

Thanks Engines, I agree, but having taken the origanal CAA regulations and converted them, removed non miltary relevant parts, or amended to fit in with the new way forward for the MAA, applied the regulations to civilan companies working within the military environment, that they did not follow themselves, or understand what it was all about, made for rather confusing and interesting times.

There are a lot in the MAA who are trying to do things right these days, but they are, as has been pointed out on numerous threads like this, sometimes overridden by the hierarchy. It also did not help when they initially filled posts with people who were not compliant with the requirements for those posts, again that just means things got lost in the noise, including safety issues, which this and other threads have illustrated.

The ASIM system using DASOR's only works when people know what should be reported in the first place, then report it if they are not bothered about career progression, and then have people who can investigate, analyse and ultimately put actions in place to stop it happening again, unfortunately it is stovepiped into individual platforms with not much thought to safety issues that could be applicable to others.

A phrase I heard regularly after Haddon Cave report came out was 'nothing to do with us, that is Nimrod only', and we all know that is not correct.

[Mortmeister]

Engines,

You have made some excellent post and identified a number of very valid points.
Having spent most of my 24 years as an armourer working on Mk.10 seats (6 on Hawk) I just need to clear up one thing.
The removal of the Scissor Shackle Bolt is something a properly trained and authorised tradesman would be very familiar with, it has to be disconnected in order to remove the primary cartridge in the top of the ejection gun, part of the dis-arming process that is carried out on every single seat removal.
In my time on Hawk (at 2 TWU 88-94) we had a training cell that monitored our qualifications, with all training carried out locally on the squadron (there never was a Q course for Hawk only an X-annotation). With that many aircraft and student pilots, we pulled seats that often that it became second nature (I could still remove one now from memory).
Back then, most of the guys on RAFAT were ex-Hawk guys from Valley, Brawdy or Chivenor, so they knew the jet well. I understand for some time now, there have been 1st tourist engineers on RAFAT, probably because there is no 'pool' of experience to draw from other Hawk units, as they have been civilianised. However, they should have had to demonstrate their competence in carrying out seat work, prior to being authorised to carry out that work and have a training record to substantiate that.
I have posted previously on this incident, but have not felt comfortable about this for some time due to comments made by certain individuals.
Certainly, on the squadron that I worked on, we were all aware of ensuring the freedom of movement of the parachute withdrawal shackle in 1988. I can only conclude that the general 'dumbing down' of training over the years and a lack of experience have contributed here.
But bear in mind, are talking about the tradesman that did the job, the NCO who carried out the Vital checks and the SNCO who did the Independent checks all missing this one critical failure of a basic task.
Why? Someone should be desperate to answer that question....

[roving]

Careful study of this extract from the BoI Report provides many of the answers.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/277779/XX177Part_1_4_3_analysis.pdf

[tucumseh]

Mortmeister

Excellent post.

Certainly, on the squadron that I worked on, we were all aware of ensuring the freedom of movement of the parachute withdrawal shackle in 1988.

I simply note that (a) MoD flatly deny this, and (b) the HSE considered it 'irrelevant' when offered in evidence, and did not think it affected their case against M-B for not reminding MoD of this in 1990. I've never worked on ejection seats, but the individual elements are basic fitting, and without hesitation believe you.

[tucumseh]

Exrigger

although it is to be noted that there is a lot of use of the word should,This is now applied to aspects that were hitherto mandated. I first saw this in about 1999 when a non-engineer line manager had a pop, saying 'Def Stans are not mandatory'. Well, they are, if called up in the contract. And a small series of them are mandated in every aviation contract. Not hundreds - just 4 or 5; and only one that any project manager should know by heart. It is THE Bible. Had it been followed, this accident would not have happened. Many of the recommendations in the SI report, and those in other reports, amount to - implement this Def Stan. Much of the content of these Standards is now 'should' instead of 'shall'. But I wonder if the MAA have actually rescinded the overarching directive that they are mandated? Very confusing for those who have to implement them.

[Exrigger]

Tucumseh, with regard Def Stans you are correct, however the RA's in one specific area were amended to remove certain information that caused problems for the contractors, the Def Stan still retained the information and was extant within the contracts, but the RA took precedence despite that.

[Vendee]

Take the trivia somewhere else please.

BGG

I don't think I will but thanks for your input.

[Nige321]

Certainly, on the squadron that I worked on, we were all aware of ensuring the freedom of movement of the parachute withdrawal shackle in 1988.

But the SI says, in section 1.4.3.9 'Drogue and Scissor Shackle from XX177'

Of note, when fitted but not deployed, lateral movement of the drogue shackle was possible, giving no indication of an interference fit until loading was applied

So waggling the shackle during preflight checks may not have picked up the overtightened bolt anyway...

[EAP86]

Tucumseh, with regard Def Stans you are correct, however the RA's in one specific area were amended to remove certain information that caused problems for the contractors, the Def Stan still retained the information and was extant within the contracts, but the RA took precedence despite that.

After a fair few years in industry dealing with such matters, I can advise that the recognised order of precedence is that the Contract terms come first, the contractual technical specification next, followed by the RAs etc. The RAs have direct relevance when it comes to the firm being awarded DAOS (or other) approval. This situation arises because there is no statutory basis for UK military airworthiness. The various arrangements are only 'legal' due to the SoS for Defence use of the Crown Perogative to mandate them. While the SoS' orders are binding on the CS and Military, they must be confirmed by contract for industry.

As an aside on the use of "Organization" within the MAA, this arose because of a minor obsession by one of the first Directors of the MAA. While this usage appears in the OED, it is regarded as archaic. A friend in the MAA once told me that the two main internal issues were the use of the 'z' in such spellings and ensuring that the interests of horse riders were given proper attention when it came to low flying and so on.

EAP

[Exrigger]

EAP86:

After a fair few years in industry dealing with such matters, I can advise that the recognised order of precedence is that the Contract terms come first, the contractual technical specification next, followed by the RAs etc.

As you say that is the correct order of precedence, however, having been involved in MRP 145 approvals since they were introduced for civilian maintenance contractors, this point was argued that the quoted contracted Def Stans took precedence over the RA's that were amended to remove pertinent information, the argument was lost and the companies have to submit a Alternative Acceptable Means of Compliance to work to the Def Stan and not the RA, attempts to amend the RA to re-align with the Def Stan were unsuccesful.

Quote from MAA-03:

1. Acceptable Means of Compliance (AMC) represents the preferred means by which the MAA expects the intent of the Regulation to be met. AMC contain the permissive verb should, highlighted in bold for visual impact, to indicate that another approach may be acceptable.
Therefore if the regulated entity believes it can better achieve the intent of the Regulation by using an Alternative AMC, it may formally apply to the MAA to have this alternative means approved.
Such approval will only be given where the regulated entity can produce evidence to show to the satisfaction of the MAA why the AAMC is necessary and appropriate in lieu of the AMC, and that the AAMC can achieve the requisite level of Air Safety by compliance with the Regulation. After
MAA approval has been given, the applicant is responsible for ensuring that the activities defined in the AAMC are promulgated, understood, and followed appropriately

And then one wonders why we keep having these threads on here, when the critical safety sytems are full of mis-understandings and confusion, or are simply not followed.

[RetiredBA/BY]

Tecumseh and engines, thank you, gentlemen, for your detailed reply.

Having read the SI it still sticks in my craw that M.B. were fined for not protecting the RAF
from itself ( at least that is how it appears to me) as there is a list of 14 contributory factors in that SI.

The one item, of several, which really disturbs me is that there was a practice of inserting the. SFH pin WITHOUT visual reference, hard to believe that such a safety critical item was so (mis) managed.

Another thing which I do not understand, and to which no one has yet given a reasonable answer:

If the pin was removed before engine start it follows that taxi OUT was conducted with a live seat.

Why, then, was the SFH pin replacement not left in place during the taxi IN and carefully replaced, with visual observation and confirmation of correct replacement, on reaching the pan and the engine shut down ?

It’s a long time since I was a QFI, (and my own ejection) but I just cannot begin to understand why such an unsafe practice was allowed, tolerated, let alone became an SOP.

Has that practice been changed following this tragic death ?

[longer ron]

there never was a Q course for Hawk only an X-annotation

There was a 'Q' course in the early days of the Hawk Mort - I did mine at Hawker Squiddelly Dunsfold june/july 1977 whilst on my way to Brawdy for the introduction of Hawks for the TWU.I do not know how many 'Q' courses were actually carried out - not that many I guess.My docs were annotated (something like) Q-AHK-A as I was a rigger.


Certainly, on the squadron that I worked on, we were all aware of ensuring the freedom of movement of the parachute withdrawal shackle in 1988


Same in 1978 - the shackle rattle was always carried out by the aircrew during pre strap in checks.

[EAP86]

Exrigger:

I feel your pain. I was involved with 'MAOS' when ADRP held it's original 'Ad Hoc Sub-Committee' on the subject, the discussions on the original Def Stan 05-130 with ADRP and EngPol, and the subsequent drafting of the relevant RAs.

It was frustrating, to say the least, to discuss issues in the meetings and achieve a degree of mutual understanding only to find that later discussions within the MAA (or with the senior officer levels) left the text unchanged or changed to something even more unacceptable. There seemed to be a view that industry could agree and accept anything and very few realised the strict legal and commercial constraints under which we operated. To be fair, this view wasn't universally held but over the years I observed many shrugs signifying "...I know, but what can I do?"

The maintenance regs were originally drafted as Def Stans because only industry was expected to work to them. Industry has always been discouraged from contracting to MOD internal regs such as JAP100, JSPs, RAs etc because they can change without any involvement from industry; thats why Def Stans existed. Many of these documents were actually caveated to say they were not to be used for contracting purposes but I'm aware that this rule was often disregarded, possibly less so in the Air domain than Land or Sea.

EAP

[Exrigger]

Thanks EAP86, I went to RAF Wyton for the original meetings on what became MAOS, and it was comical listening to what was being put forward and the surprise when industry pointed out that some of their ideas would not work. With regard MAP-01 & 02, JAP 02 & 02 as was, were included in the maintenace contracts as there was RAF personnel as part of the workforce and we had to use military paperwork, F700 etc, on that score civilian companies had issues with that as they were wanting to run things independantly from the military, but with MRP-145 approvals and reality kicked in it was realised that this approach would be impractical.

It was also pointed out that RA AMC's quite often link to the MAP-01, so despite trying to deny the link and ignore the MAP-01, to maintain approval the companies have to comply.

Again, it does make one wonder if all this confusion is partly responsible for having the opposite effect on safety than it is designed to safe guard and improve.

[Fitter2]

I read with interest the BOI analysis. I don't know when the requirement for OJT to be carried out by trained Instructors, or personnel having received sufficient training on instructing was introduced. Certainly it was not practice in the 1960s, when I both received and carried out OJT. On the 2 occasions when I gave evidence to a BOI, my technical ability and use and availability of documentation was queried, and the BOI satisfied, but formal training qualifications were never raised as an issue or contributory factor.

[tucumseh]

Thank you those who are more up to date than I.

There is a formal 'Order of Preference or Hierarchy for the Selection of Standards for MoD Acquisition'. My copy pre-dates the MAA, but Defence Standards sit above UK MoD Departmental Standards and Specifications. I don't have a copy which says where the MAA documents sit.

In aviation, this was complemented by Controller Aircraft Instructions, mandated upon every member of Air Systems Controllerate. The 05-Series of Procedural Defence Standards were mandated in every aviation contract. This was the one area where Def Stans sat above 'Recognised Industry Standards'. Which is just another way of saying what others have confirmed.

What was immediately obvious to me when the MAA started producing all this 'regulatory set' was, in key areas (e.g. maintaining the build standard, which is what would have avoided so many deaths) their words reflected, almost word for word, the aborted Chief of Defence Procurement Instructions (CDPIs) from 1993. The MAA made precisely the same mistake in its definition, and immediately went off at a tangent. As far as I know, this is still the case (based on a word search of key words). The problem was, the money had already been withdrawn to maintain the perfectly good 05-Series Def Stan, and eventually it was scrapped. So, today there are no laid down procedures that industry agree with. It might accept a contract lacking it, but I'll lay money its engineers have a copy of the Standard in their top drawers. Both Parts. I'd lay more money on MoD not being able to produce Part 2 at all, and only having an old version of Part 1, at best. That Standard was not written or issued by ADRP. It was written and maintained by the Technical Agencies I mentioned earlier. My old boss's name is still in my copy, promulgating the last update - which we had written to reflect changes in legislation.

This all may sound faffy, but it is the foundations upon which the safety aircrew take for granted are laid. Its money in the bank and costs peanuts to implement, because the work is not volume-related. You know within a very small margin how much the annual cost is. Getting it wrong costs an awful lot more, and not just after an accident.

[Exrigger]

Tucumseh, these RA's might be applicable to that area, although the manner this was complied with on one platform was much to be desired and initally added not a lot to safety/airworthiness:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/460570/RA4970_Issue_2.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/465309/RA4971_Issue_2.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/460576/RA4972_Issue_2.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/460578/RA4974_Issue_2.pdf

As in previous post, the qualification requirements laid down within these RA's were not fully complied with when positions were originally staffed, probably due to the lack of SQEP's available to fulfill the posts when the requirements were first laid down.

I will leave it up to others more current on this to decide if this has been sorted, though I still think the implementation, and a word I hate, i.e interpretation, of the regulations is still letting safety incidences slip through in all the confusion.

Sorry forgot this one:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/460577/RA4973_Issue_2.pdf

[Exrigger]

For those interested here is the Def Stan list, 05-61 Quality was one I remember being in company contracts, there were others, but have been out of the loop for a while, even renewed contracts seemed to hang onto some that were obsolete, but nobody seemed bothered, even some in the military did not know that ones they quoted were obsolete.

https://www.dstan.mod.uk/StanMIS/Indexes/DefenceStandards

[tucumseh]

Exrigger

Thanks. If you just take the first one, RA4970, para 2 (Tolerable and ALARP).....

Completely ignored in this XX177 case. MoD denied it knew the area of risk was NOT ALARP. It concealed the evidence that showed it not to be ALARP since 1990, and that it had rejected the modification that would eliminate the risk. When revealed (last month), MoD and HSE declared it irrelevant. I'm afraid I have no confidence in the MAA when they tolerate this.

This RA doesn't introduce the concept of tolerable and ALARP. Like most MAA documents, it simply re-phrases existing and perfectly good procedures, regulations and instructions. I'm sorry if I upset anyone, but there are a raft, perhaps hundreds of 'SO3/2/1' working on these as if they were staff papers, oblivious to the fact that very junior MoD staff know it all backwards, and laugh at the ineptitude of it all. I learned a lot of this stuff from a 4th year apprentice, when I was a year behind him. And God knows I was backward and a slow learner.

[pulse1]

Post 462 - Engines

(To their considerable credit, a very smart Gp Capt engineer did just that a couple of years later - I cherish a hope that the sight of the RN's slimline stack of books might have helped start that process).

You wouldn't happen to know the initials of this Gp Capt engineer would you. It's just that, coincidence or what, my wife has invited some new neighbours for dinner this evening and he is a retired Gp Capt engineer. I know that this subject will come up because he has just finished reading "Their Greatest Disgrace" by David Hill. I am looking forward to hearing his views.

[Exrigger]

Tucumseh, having worked within these so called new regulations within civilian companies and having spent the 30 years previous trying to maintain safety/airworthiness IAW the same regulations that they came from, I was, in both cases, frustrated, annoyed and numerous occasions brought the wrath of management on myself when I pointed out the more flagrant mis-interpretations, or non-compliances, even when I submitted amendments to remove introduced errors which were turned down.

I do get down when the avoidable is repeated by the lack of understanding of, erosion of, or the ignoring of those very sytems meant to stop these occurrences, surely they must wake up and realise this, the evidence is there for all to see.

[airpolice]

Is there a third way?

I think the thread is pointing towards, for each type in service, they either;

Write the book from scratch.

Or,

Go back to version 1 and amend it carefully with full input from manufacturers and engineers. Documenting along the way.

The MoD should of course, stop flying until the books are complete, and procedures are in place. But only if they want stop people dying in them.

Unthinkable perhaps.

How unthinkable is another preventable death?

[Rigga]

Exrigger,

Due to my civil airline maintenance and operations experiences, I too was once employed to try and implement MIL Part M (at the time it was Def Stan 05-130 - MAOS Part M) to the Company I worked with and also to educate and advise the RAF contingent with my scope of work.

I have to say that I did make some large waves in changing company and some RAF attitudes to the MAOS regulations and their associated processes. However, there was also a great deal of resistance/retaliation from the customer against their own regulations. I managed to hold my job for four years before giving up in sheer frustration, with the customer attitudes, and going back to civvy street where I had a much less stressful time holding nine EASA Forms 4.

In that relatively short tenure, I found that the (quite hostile) EA had no clue as to how they should respond to reliability reports or any other findings from their contractors, to the point where the EA were forced to surrender there maintenance program duties (and the cost of a £6m contract) because their 'avoidance of airworthiness actions' were placed on a company Risk Register and displayed to their DH.

That EA had no method of recording or even researching defect trends within their single platform and displayed some 'alternate' priorities in their duties. In fact their own history documented the EA's lack of action and attention for the previous 20 years!

[Distant Voice]

The following is an extract from the evidence given by Air Marshal Richard Garwood to the Defence Committee, in respect to Duty of Care, on 29th Nov 2016.

"I think it goes back to, as Sir Charles Haddon-Cave put forward in his report, that this must be about personal accountability and not corporate or wider accountability. That is why we now have the three-layered or four-layered Duty Holder construct with the fourth being the Secretary of State for Defence. If we had a fatality in the military tomorrow, I could give you the four names for any part of military defence who have accepted personal accountability for that. Perhaps I could refer to one of our Duty Holder letters from the Chief of the Air Staff, Sir Andrew Pulford to Air Vice Marshal Turner, who is an Operating Duty Holder. Line 4 of the letter says: “You are personally legally responsible and accountable through the Secretary of State for air safety, the air systems and functional safety in your area of responsibility.” We are now crystal clear in the military about where that accountability lies and it is not at lower levels, but at pretty senior levels: Lieutenant Colonel up to Chief of the Air Staff in this instance, and above to the Secretary of State."

RA 1210 makes it clear that in the event of a fatality the Duty Holder is expected to defend his Safety statement in a court of law. So where were these guys in the Red Arrow case? In fact where were these guys in Tornado collision case, the Lynx case, the Puma case? In the shadows protecting their pensions. The MAA regulations are just "paper talk" that have got nothing to do with airworthiness and saving lives. Since the introduction of Haddon-Cave's duty holder concept not one senior officer has been called on to defend his safety statement (Tolerable and ALARP) in a court of law.

In recent email the MAA advised me that, "It should be noted that the validity of an ALARP argument can only be decided definitively by the courts, in the event of an accident". Do coroners and judges know that?

DV

[tucumseh]

DV

Excellent.

But who determines who appears in court to answer? It seems to be MoD, and the judiciary and Coroner's Service roll over. One of the more obvious examples was at the Mull of Kintyre Fatal Accident Inquiry (into the deaths of the RUC and civilian MI5 officers - not the Service personnel - a subtlety which I know interests you). The families were looking forward to engaging with the Air Marshals, but they were a no show. The MoD QC immediately asked the Sheriff to confirm that, if the author of evidence was not in court, then that evidence could not be produced. He agreed. (Probably had to agree, if that is the law). This renders RA1210 meaningless.

Possibly the most senior officer to appear is Admiral Massey, at the Sea King ASaC mid-air inquest in 2007. His evidence was tainted straight away by claiming the Mk7 is a two-pilot aircraft, and that two pilots (even if there were two) render electronic sensors redundant. So, it didn't matter that they were degraded in one aircraft, and not switched on in the other. His evidence is relevant to this Red Arrows case, because it reveals serous ignorance of the concept of defences in depth. Flt Lt Cunningham's parachute was the final defence. Seldom is it mentioned that a number of other defences failed entirely. None were Martin-Baker responsibilities. They didn't fail by accident. Many were as a result of MoD's policy and practice of savings at the expense of safety. If you strip away defences, the outcome is easily foreseen.

[Chugalug2]

Exactly tuc! Anyone can make reassuring commitments to ruthlessly holding VSO Duty Holders to account, but it is by their actions that we should judge them. In reality none of them are held to account but instead protected with a tissue of lies of omission and commission, and by persecuting their juniors in life and even in death. The whole concept that the MOD, the perpetrator in this scandal, should be judge and jury of its own case is risible.

If the results of this dysfunctional and corrupt system were not so tragic it would make for an amusing plot for Yes Minister. There is nothing amusing or redeeming about the MOD. No matter how the goal posts are moved or relabelled, UK Military Air Safety remains at the mercy of further subversion and suborning by VSOs. It has to be freed from their grasp, and Regulator and Investigator made independent of the MOD and of each other.

[tucumseh]

Perhaps I should add it was slightly unfair of me to mention Admiral Massey, as he had the decency to appear - unlike others. I'm sure he understands the concept in the context of being boss of a carrier group. I'm equally sure the families would have preferred to hear from the MoD employees who lied to the Board of Inquiry and other investigations.

In this case, I'm sure Mr Cunningham would have wished to hear why the modification that would have saved his son was not adopted in 1990. Even the judge expressed concern that MoD's star witness wasn't in court. And as for the HSE's star witness.... Are safety cases now irrelevant to the decision to release to service? Has the MAA changed things so much?

[Exrigger]

Rigga, we are talking the same groups of people, just different platforms.

As to the MAA in its entirety, it makes one wonder how they can take the regulatory set from the CAA to align the military with that system, a system (CAA's) that would appear to be robust and work within civilian aviation, convert it into a system that they did not appear to know how to integrate it within the military system, causes issues for civilian contractors who find it hard to work within both systems, especialy when the military one appears confusing, and in some parts makes no sense after translation into military speak.

Was was this done on purpose, I highly doubt it, was it lack of knowledge of those who wanted to make the change, thinking it might make things better within the military and just translated it incorrectly, was it the lack of understanding that got them where they currently are, is there the will and knowledge to fix it, do they actualy believe it is not working as advertised, do those at the top want it fixing, as it would appear that the obfuscation of safety/airworthiness systems could actually keep those at the top out of reach when issues arise, issues like the subject of this thread and many more.

I will state that these are my observations from my involvement on various platforms since inception, but hopefully things noted above and in other posts may have been, or in the progress of being fixed, only those still working today, both civilian and military can answer that, would presume it would also depend on where in the food chain those people sit as to whether it is ok, or not, though historically the higher up the person is, the less there are perceived problems.

As I posted before the BMAR should have picked up these issues with work carried out, inclding, MODs, SI's etc, or not as the case may be, and the annual MAR should maintain that survellience of work done, or what should of been done, before issuing the next years certificate to fly.

[frodo_monkey]

Tecumseh and engines, thank you, gentlemen, for your detailed reply.

Having read the SI it still sticks in my craw that M.B. were fined for not protecting the RAF
from itself ( at least that is how it appears to me) as there is a list of 14 contributory factors in that SI.

The one item, of several, which really disturbs me is that there was a practice of inserting the. SFH pin WITHOUT visual reference, hard to believe that such a safety critical item was so (mis) managed.

Another thing which I do not understand, and to which no one has yet given a reasonable answer:

If the pin was removed before engine start it follows that taxi OUT was conducted with a live seat.

Why, then, was the SFH pin replacement not left in place during the taxi IN and carefully replaced, with visual observation and confirmation of correct replacement, on reaching the pan and the engine shut down ?

It’s a long time since I was a QFI, (and my own ejection) but I just cannot begin to understand why such an unsafe practice was allowed, tolerated, let alone became an SOP.

Has that practice been changed following this tragic death ?

I haven’t flown a Hawk for a long time, but how do you propose “showing someone that the pin is in the seat”? By definition the pin is fitted to the seat pan handle and therefore can’t be seen easily from outside..

Certainly on my own fleet the pin is shown to the ground crew prior to taxy, then inserted into the stowage which is below the cockpit sides.

[tucumseh]

Exrigger

-re CAA. As an MoD apprentice, I was examined against both MoD's rules and procedures, and the CAA's Civil Aircraft Inspection Procedures. Even had to buy our own CAIP Leaflets! Still got them. To me, this demonstrates MoD had very close links to the CAA. Is the wheel being reinvented again? When did MoD stop training its maintainers to both sets of rules?

[Exrigger]

Tucumseh, I am not able to answer those types of questions, as from my involvement I was only ever applying the military version and trying to get the military side to work to those and together, but it was often a wasted effort.

My posts have been based on my experiences, and I have been out of a constantly changing environment for a while, which is why it would be interesting to get a view of the current 'in work' personnel from both military and civilian personnel on bases to provide their view of the system today, something I would be very interested in.

Of note, the Lead Auditors for MRP-145 approvals are usually from the CAA, which has produced some interesting 'audit' findings.

[Rigga]

Tuc and Exrigger,

From my POV the resistance to regulatory change came from the embryonic MAA itself. I met and chatted with the guy who drafted 05-130 (Parts 145 and M) who said that it was messed about after 'acceptance' of the draft and prior to publishing. The dis-jointedness of its content shocked him.

Shortly after my first reading of Mil Part M, I noticed that it could not work because someone had not permitted the issue of a 'MIL Form 1', an essential part of that regulatory system. I assumed, rightly or wrongly, that this was down to the powers in MOD reading 'Form 1' as simple replacement for a 'Serviceable Label' (MOD Form 735) and ignoring it. i.e. they didn't understand the Form 1s significance.

Those MAOS and DAOS standards defined personnel responsible for tasks and part of my job was to educate, explain and clarify why the Accountable Manager (which became the nominated DH) could not be a Group Captain and had to be the budget holder, not a mere budget manager. i.e. the person who gave the Group Captain his budget to manage.

Post H-C, the first thing the MAA did was not to try and adopt the MAOS/DAOS standards, but to squeeze the bits of those standards into where they already "complied" and then set about re-wording all the other bits (through issuing the new set of RAs) to suit the status quo. In essence: some Post-It Notes had been placed on the regulatory wall, but all the cracks had only been cleaned, not even whitewashed, to look more presentable.

The use of Airworthiness Reviews fell at their first attempt when that aircraft failed the very first AR question (it did not have a valid Maintenance Programme) but this was ignored by a certain Eng O and stated as a Pass! (I again assumed that this Eng O was chasing a promotion rather than proving a system worked)

As for training standards, there are now serving technicians with EASA Part 66 licences to allow them to work on A330, A400, G500, Beech350 and the like. Also, I believe the Cosford syllabus is similar to EASA standards, probably because MOD can't staff its own full training syllabus. Finally, the EU Mil Airworthiness Regs (EMARs) also cover technician training so there may be some input there too.

[Rigga]

I have just observed my own statement, above, and realised how the civil aircraft types mentioned reflect how the EMAR systems may move toward in the future. With a clear difference between 'Airworthiness' (as apparently governed by the needs of EASA and civilian licensing of maintenance techs) and 'Role Equipment' which I define as those systems which do not have a direct effect on the aircraft's ability to maintain flight and land under control.

Food for thought.

[EAP86]

In recent email the MAA advised me that, "It should be noted that the validity of an ALARP argument can only be decided definitively by the courts, in the event of an accident". Do coroners and judges know that?


DV I'm assuming that this is a real question, not rhetorical. I can only speak from an industry perspective but having had many discussions on ALARP with members of the MAA, it may be helpful.

We were advised (by legal qualified officers) that in the event of an accident and consequential court action, any safety determination we had made could be expected to be investigated by the likes of the HSE or courts to establish whether the legal criteria had been met. Key to that would be questioning in court to examine whether the hazards had been eliminated or mitigated to the degree mandated by the Act. The MAA is quite right; as a matter of law its what the court determines that matters - the criterion exists for the courts to apply. The legal eagles did try to prevent our use of the ALARP term odd times in case it annoyed the courts.

EAP

[EAP86]

Finally, the EU Mil Airworthiness Regs (EMARs) also cover technician training so there may be some input there too.

Rigga, forgive me for correcting this but in today's environment, I think we have to be careful about the use of the term "EU". The EMARs are properly termed the "European Military Airworthiness Requirements". While the creation of the EMARs was coordinated by the EDA, an agency of the EU, they did so at the request of the 27 pMS (participating Member States) involved - Denmark chose not to participate. At the outset it was recognised that the EMARs could not be regarded as Regulations as neither the EU nor EC had any authority to mandate or enforce them. Making them into proper Regulations could only be achieved by the relevant States incorporating their content into their own regulatory arrangements. Rather than following the Civil regs slavishly, the EMARs contained the basic processes thus allowing the individual States to tailor them as necessary for their national environment.

Its worth noting that the UK took a very strong part in the process of developing the EMARs. The various tasks were separated into four multi-State Task Forces, two of which were chaired by UK MAA staff, the other two being chaired by Italy and France. I think its no secret that the MAA used the EMARs to develop new regulatory arrangements rather than developing UK only approaches. For example, refresh of the DAOS regs was delayed until EMAR 21 was completed. EMAR 66 was also regarded that way but was proving tricky to implement - I've lost touch so it might be there now.

If anyone is interested, the MAWA website can be found here: https://www.eda.europa.eu/experts/airworthiness

EAP

[tucumseh]

EAP86, Rigga, et al

Many Thanks.

Haddon-Cave confirmed the real problem is implementation. He didn't uncover this, he was just pointed to directives that staff should NOT implement them, but falsely declare they had. That, surely, is where the MAA should have been focusing attention.

Looking at at well over 70 deaths discussed here over the years, I can point straight to the 'old' regulations, set out in one Def Stan and one chapter of another, that, if implemented, would have avoided them. I can't identify the same conciseness in the MAA regs. To me, that means the MAA has gone down the wrong path. The Hawk XX177 accident rather proves the point.

I know the MAA set about auditing project teams when it was formed in 2010. But if this didn't reveal the invalid Hawk safety case and lack of basic audit trail, then it didn't ask the right questions.

[EAP86]

That, surely, is where the MAA should have been focusing attention.


To be fair to the MAA they did establish their plans early on, structuring them as 10 separate workstreams and I believe the implementation issue was a serious driver. The creation of the Duty Holder construct was an attempt to establish clear obligations for those charged with the responsibility for the various aspects of military aviation safety to improve implementation.

As regards the regs/EMAR aspect, I think they also recognised that the existing regs had developed over the years in a higgledy piggledy fashion and were somewhat lacking. Courts tend to recognise the civil regs as a sort of 'gold standard' and basing future regs on the civil approach was a shrewd move. Harmonisation of the regs across the various National approaches in Europe also tended to enhance the regs' status in the eyes of Courts (we're following International best practice etc...) and shared the rule making task across a larger number of competent people. Note that the UK wasn't the only Nation worrying that their regulatory arrangements were not fit for purpose, faults having been brought to light by the findings following fatal accidents.

Without going into details, I believe that the MAA's audits did find issues within the PTs but they accepted that efforts to correct the failings were in progress so further time for compliance was granted. Some issues will take quite a time to fix but I've been away from the sharp end for some years and I have no feel for the current state of play.

EAP

[RetiredBA/BY]

I haven’t flown a Hawk for a long time, but how do you propose “showing someone that the pin is in the seat”? By definition the pin is fitted to the seat pan handle and therefore can’t be seen easily from outside..

Certainly on my own fleet the pin is shown to the ground crew prior to taxy, then inserted into the stowage which is below the cockpit sides.

Perhaps you misunderstood or I did not make myself clear.
What I meant is that the seat pin should be left in place after landing, IN ITS FLIGHT STOWAGE until the pan is reached, engine shutdown and then carefully replaced with visual observation, by the occupant, of correct insertion, NOT doing it by feel during taxi in when eyes should be outside particularly with other aircraft in close proximity.

That’s the way it was done during my time 12 years on ejection seats and I still feel it is the safer and better procedure.

That was on mk2, 3 & 4 seats so perhaps there are good reasons, no one has yet explained, that the Mk10 has to be different.