Martin Baker to be prosecuted over death of Flt Lt. Sean Cunningham [Archive] - Page 3

Chugalug2

2nd Mar 2018, 22:34

Rigga, cracking post! Short, sweet, and succinct, yet it contains all that has gone wrong with UK Military Airworthiness, why it went wrong, and who is responsible for making it go wrong.

We need to keep our eye on the woods for fear of getting obsessed with the various trees. This tragedy, and every other tragedy featured in UK Military Airworthiness Related Fatal Accident threads on this forum, are all connected by the dysfunctional system that you highlight. RAF VSOs have been the downfall of an Air Safety System that used to be an international leader. Now it simply adds victim after victim to its death list, and hacks away at the very vitals of UK Air Power. The VSOs responsible are protected by a cover up that inhibits reform of both Regulator and Investigator. Whether the RAF is prepared to clean out its own stables is for it to decide. What cannot be allowed to continue is the baleful effect its leadership has on UK Military Air Regulation and Investigation. Both must be removed from its influence and made independent of the MOD and of each other.

This has to be faced up to now and the nettle grasped. Aviation doesn't tolerate a dysfunctional system and tends to be merciless in response. We need to be equally merciless and stop this rot now!

tucumseh

3rd Mar 2018, 07:36

Rigga

Your example relies on honest answering...not a prominent trait in many MOD/RAF positionsBut it helps if you already know the answer! I've stood in front of an entire IPT and heard #3. The only person who actually understood the question and agreed with me used to work in Directorate of Air Armaments. Another defensive barrier that has disappeared.

Exrigger

3rd Mar 2018, 09:04

The 'say yes and get on' problem is a real killer of airworthiness issues and regulatory progression. Mainly caused, as you imply, by the short-tour officers in a very largely influential post. It is these career-minded idiots that risk many peoples lives by their Trump-like decisions, but borne out of promotion targets and their next tour.

Tuc,
Your example relies on honest answering...not a prominent trait in many MOD/RAF positions, in my experience - See Eng Os actions in my previous post and the above statement.

In all honesty you can apply that to some within the civilian companies that are trying to work to the same regulations, and have to engage with these military versions described by Rigga, one example when trying to get a Squadron JENGO to follow the regulations, his response was "You civilians just don't understand how the military system works", in fairness some did not, but this only emphasised how little he and others in the military, with a similar view, actually know about 'their regulations'.

Chugalug2

3rd Mar 2018, 09:19

ER:-
when trying to get a Squadron JENGO to follow the regulations, his response was "You civilians just don't understand how the military system works"
The response to which is, "Well neither do you!".

The "system" that he knows is a sham. The system that he has been taught is a corrupt and dysfunctional one. The system that he should have been taught was destroyed in Haddon-Cave's "Golden Period", deliberately and with malice by RAF VSOs. As a result he is a liability, not an asset. He is now part of the problem.

As to civilian companies (including MBA) having difficulty coping with this shambles, of course they do! Who wouldn't? But it is the Military who created the shambles and it is they who should face up to the reality, stop the cover up, and co-operate in the reform of UK Military Airworthiness and Accident Investigation by both becoming truly independent of the MOD and of each other.

Exrigger

3rd Mar 2018, 09:45

Chugalug2, agree up to point, having dealt with said JENGO in a similar manner to what you suggested, though it was a couple of RA's that he reckoned only applied to the civilian companies, not to the military, by that attitude the squadron/station were causing an issue for the civilian companies and risking their compliance/approval, again he learnt the error of that view eventually.

Yes the civilian companies do have problems coping with the military system shambles, but there were still those that went with the flow of the military view just to make sure the contract/approvals were not put at risk, or avoid any come back on them, and lastly to make their days easier.

The net effect is a buggers muddle that won't stop accidents and incidences until the message gets through to the 'management' that they cannot keep changing things and then not follow those very regulations, whichever ones they finally hang their hats on, that are supposed to prevent these very things from happening.

Chugalug2

3rd Mar 2018, 10:58

ER:-
but there were still those that went with the flow of the military view just to make sure the contract/approvals were not put at risk, or avoid any come back on them, and lastly to make their days easier.
I don't doubt it, bad apples and all that, but like your JENGO they are symptoms of the problem rather than its cause. The problem is the UK Military Air Regulator itself, staffed as it is by many who were complicit in creating or covering up this scandal. It is fatally compromised by its inability to acknowledge what really happened, who were really responsible, and instead clings to the fiction of the Haddon-Cave "Golden Period".

No matter how many new regulations the MAA dreams up, UK Military Airworthiness will remain the buggers muddle that you so aptly term it. Nothing short of a root and branch reform will suffice, starting with replacing the MAA and the MilAAIB (or whatever the sign outside reads this week) with truly independent civilian led versions. Now this may bring to mind the words Turkeys and Christmas, but anything less will simply prolong the agony, cost yet more life and treasure, and further compromise our national security.

Exrigger

3rd Mar 2018, 11:08

starting with replacing the MAA and the MilAAIB (or whatever the sign outside reads this week) with truly independent civilian run versions

That won't happen when a lot of the military currently blame civilian contractors for all their issues in the first place, and secondly they don't think it is broken, which is the most dangerous issue with it all.

Distant Voice

3rd Mar 2018, 11:08

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.

Yes, it was a real question, because since the introduction of RA 1210 not one ODH has appeared in court, or at an inquest. The way I read the regulation, in the case of the Red Arrow accident, the AOC 22 Group should have appeared at the inquest and justified how his platform (and seat) met the tolerable and ALARP criteria that he had signed off on.

DV

Rigga

3rd Mar 2018, 11:20

Exrigger

3rd Mar 2018, 11:50

That principle, in civilian companies, is generally evaded by the incumbent being a specialist in a particular field, not having any other predetermined place to go for a good few years, if ever, and who is paid for his performance in that position, not for his title regardless of performance.

My observation earlier must have been misplaced when I said we had worked under the same people just different platforms, as there were quite a few that your observation did/does not apply to, some thankfully were moved, some are in the same post but different platform and has not changed their outlook, and I would still say that your comment below applies to some within the civilian world from my experience, that is all I am saying, neither which helps sort the mess the military have got themselves into, as I said earlier they don't accept it is broken and untill they do, nothing will change and fully agree with what you have written which supports my views and experience:

most RAF officers don't know how their 'system' works. Like their mechanics/technicians, they were taught it at school but it is beaten out of them as soon as the arrive in a real post where "we dont do it like that here" comes into play.

Chugalug2

3rd Mar 2018, 13:22

ER:- they don't think it is broken, which is the most dangerous issue with it all.

Absolutely bang on! My perpetual, irritating, and very annoying slogan is;

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

You sum it up more succinctly and convincingly than I, so thank you! Here we have the dilemma that the very people who need to take urgent life saving action are instead in total denial. They may well be judge and jury of their own case, but there are others above them in Government, Parliament, the Judiciary, Law Enforcement, who have the power to bring them to task and demand changes. Unfortunately each of those institutions have singularly failed to date in their duty to do so, often taking direction from the MOD for their inaction. That is the extent of this scandal, that is what has to change.

Of course it is easier to roll over and say that, "It just ain't going to happen". My answer is that it has to. The RAF cannot ground any more fleets, it cannot accept the unairworthiness infecting its aircraft, it cannot go on protecting certain VSOs at the cost of others' lives, without fatally affecting its operational raison d'etre, to defend our skies and to deny them to our enemies.

oldmansquipper

3rd Mar 2018, 14:16

Exrigger,
"In all honesty you can apply that to some within the civilian companies that are trying to work to the same regulations"

That principle, in civilian companies, is generally evaded by the incumbent being a specialist in a particular field, not having any other predetermined place to go for a good few years, if ever, and who is paid for his performance in that position, not for his title regardless of performance.

In my lowly opinion, most RAF officers don't know how their 'system' works. Like their mechanics/technicians, they were taught it at school but it is beaten out of them as soon as the arrive in a real post where "we dont do it like that here" comes into play. If they dont play along they get the boot.

At Station levels the RAF is only interested in their next sortie(s). This tunnelled vision practice excludes ALL other influences from their Silo (Squadron) in which they concentrate their efforts. OCs, ENGOs and JENGOs are there solely to allow the next sortie to be flown. This is fine in times of war/conflict but has no airworthiness point at all. And my point here is that it is fine in times of war! In the UK we are not at war...I have my response for those that say we are...

One of my questions to the customer, to try and understand their duplicity in maintenance, was "Why did the RAF ban BDR Techniques because they were deemed unsafe but then allow, and even quietly promote, the ignorance of 'mandated' procedures in maintaining their aircraft?" No reply...

Interesting points made, multiriggas.

IMHO In the 80s and early 90s the practice of EA staff officers on 'short' tours, unashamedly getting career path 'ticks in the box' was a major contributor to what followed. I was in EA and EA related staff jobs for 15 consecutive years. (and, as a WO, despite that I had NO formal staff training at any point - I hit the ground running) From personal experience, even a good SO2 or SO3 grade posted in would take the best part of a year to 'learn the ropes'. (None of them were specialists) We would probably then get 9 months productive work before their minds were on their next career move.

Driving down 'Airworthiness responsibility' by delegation to those (SO2/3) levels was (again IMHO) ill advised, to say the least. There was no stability, and I suspect that the quality of the staff officer output throughout was probably linked with personal career pattern and prospects. It certainly meant that stress levels amongst us 'pond life' were kept extremely high.

I thoroughly enjoyed my time in staff work, but the historical airworthiness related issues, which went on way above my pay grade of course and covered at length here, leaves me extremely sad.

Rigga

3rd Mar 2018, 15:07

OMS, your timescale and mine differ by some years. You: 80's to 90's. Me: 2010-2014.

But we have both seen the same practices, and shown our concerns, indicating the longevity of error and continuance of this folly from the pre-H-C era into the so-called 'new' MAA.

As in many civil companies when a new management takes over; all that really happens is the Coveralls that staff wear change colours. So the same old practices are still in place in the 'new' MAA organisation.

"If nothing changes, it'll stay the same." Tern Hill, ASF toilet, 1970's....(it made me laugh then!)

oldmansquipper

3rd Mar 2018, 16:30

Yes R, we do differ in timescale. I started in EA staffwork in 85 and left the service in 01, but the decline really started around 90 time, and each cut was usually billed as an 'efficiency measure'. From my perspective the constant chopping of budgets merely to massage an ego or two ("look at how much I've saved") didn't help. For example. In '85 I can recall writing my own STIs and SIs (titles in old money) content that top cover was there in the form of many levels of scrutiny and approval I would need to circumvent on the way to publication. I was also more than happy that I could convince those in the chain that my instructions were safe, sensible and practical. Regular contact with DAs via LTCs and Mods committees chaired by PE made sure of an auditable and seamless record of activity.

I gather most of those checks and balances have now disappeared. Some efficiency measure that?

EAP86

3rd Mar 2018, 21:18

The way I read the regulation, in the case of the Red Arrow accident, the AOC 22 Group should have appeared at the inquest and justified how his platform (and seat) met the tolerable and ALARP criteria that he had signed off on.

DV,

Unfortunately the HSE chose not to charge any of the DHs (or other MOD individuals) involved and, of course, they cannot take the MOD to court. BTW the 'tolerable' bit of 'tolerable and ALARP' isn't part of UK law, just part of the MAA's regs. I'd expect the court to interrogate witnesses about previous safety incidents and what was done to fix any failings arising. If the witness cannot answer with details showing that they did everything they reasonably could to prevent recurrence, they may be in some trouble. A Solicitor once told me that the best layman's definition of ALARP is "what would you tell the Judge?"

EAP

Rigga

3rd Mar 2018, 21:26

OMS, well done for doing the full whack.
I have no concept of the workings of an EA/PTL except (2010-2014) those I dealt with who didn't very much in the way of Maintenance Programme updates (Maintenance Schedule updates) apart from reacting to emergent issues warranting their attention.

I was a rigga from 75-99 and I've worked in airline and MRO quality and continued airworthinesss management since then. As an "aviation" Quality Manager I never touch ISO9001 (QMS is not a legal requirement) so I concentrate on regulations and practices to cut costs in a legal and risk averse fashion.

reader8

4th Mar 2018, 07:04

Reader8,
The 'say yes and get on' problem is a real killer of airworthiness issues and regulatory progression. Mainly caused, as you imply, by the short-tour officers in a very largely influential post. It is these career-minded idiots that risk many peoples lives by their Trump-like decisions, but borne out of promotion targets and their next tour.

I only met two that were career minded in the sense that you felt inconvenient truths were just being kept close hold, and one definitely wasn't an idiot.

The others weren't career minded idiots, they were good people. They wanted and needed to get on, but falling on your sword, even at EA level, is frankly unlikely to cause more than a small stir as a new EA is found. It's more nuanced. If they don't do it somebody else will. They understood the issues but found themselves in an impossible situation inside an organisation with a deeply flawed culture where staffwork and a good thesaurus were the answer to all problems (The rest of the world does it another way, but why let that concern the path were on). The nub of the problem didn't really lie with the EA anyway, it lay with the customer who knew that they had to fly the things. Many problems were of the customers own making (how many E3's in the green today, what did we tell the Minister last year) and required an ever deeper hole to be dug, some were frankly down to the awful politics of everything at that level, and the fact that the Sun is equally happy to write about things not being pushed far enough (Aircraft grounded in RAF Chaos, there's a war on don't-ya-know) as they are when disaster strikes.

In the end, I just felt that it was 'Yes Minister's writ large, and everybody actually relaxed when the truth was told and they knew where they were.

Unfortunately, that was rarely where the MAA wanted them to be, but that's just another side of the same coin that's significantly unbalanced in weighing resources against tasks against aspirations.

It's quite possible that there was genuinely somebody at the top who was longing to hear the problem and truly accepted that termination was an option. I never had the impression that anybody at 1* level was keen to test the hypothesis, which gives those at the top a perfect get-out (Yes your honour, of course I would have stopped straight away, had I only known). Yeah, right.

For all people can hand-wring about RA's, EA's and DH's the reality from my viewpoint was that they were window dressing to the root cause, which was the naked emperor that is the cause of most good staffwork in non-operational matters.

I didn't envy the DH.

tucumseh

4th Mar 2018, 08:10

I didn't envy the DH.

This entire 'construct' is, I believe, flawed for a number of reasons. Today's 'Duty Holders' are unlikely to understand or have experienced how to actually deliver and maintain airworthiness. They may know small bits of it, but are more likely to have an inkling about Fitness for Purpose. You can see this in the MAA's regulatory set, which to a large degree concentrates on FFP to the exclusion of the pre-requisites.

The last time I spoke to a senior officer in the MAA, he didn't understand the difference; which was also evident at the C-130 XV179 Inquest in 2008, when the IPTL simply hadn't a clue about his primary role. He didn't say 'of course I would have stopped straight away, had I only known'. He simply denied that he had anything to do with it; and even if he knew what to do, he wasn't allowed to. The families were left wondering who the hell was responsible. The implication was it was all the fault of some junior officer out in Iraq who, somehow, was meant to go and buy some Explosion Suppressant Foam and stuff it in fuel tanks. That's not criticism of either officer. Nothing in their background prepared them for their roles. Nothing has changed.

Engineering Authorities (by which I mean SNCOs and junior officers) are more likely to understand quite a lot about all three areas. I always found the EAs in all three Services superb. But, reader8, you are right in saying very few would speak out, especially when (by definition) you're complaining about a VSO. Slightly easier for civilians, but MoD personnel policy has effectively got rid of any experience.

reader8

4th Mar 2018, 08:24

This entire 'construct' is, I believe, flawed for a number of reasons. Today's 'Duty Holders' are unlikely to understand or have experienced how to actually deliver and maintain airworthiness. They may know small bits of it, but are more likely to have an inkling about Fitness for Purpose. You can see this in the MAA's regulatory set, which to a large degree concentrates on FFP to the exclusion of the pre-requisites.

The last time I spoke to a senior officer in the MAA, he didn't understand the difference; which was also evident at the C-130 XV179 Inquest in 2008, when the IPTL simply hadn't a clue about his primary role. He didn't say 'of course I would have stopped straight away, had I only known'. He simply denied that he had anything to do with it; and even if he knew what to do, he wasn't allowed to. The families were left wondering who the hell was responsible. The implication was it was all the fault of some junior officer out in Iraq who, somehow, was meant to go and buy some Explosion Suppressant Foam and stuff it in fuel tanks. That's not criticism of either officer. Nothing in their background prepared them for their roles. Nothing has changed.

Engineering Authorities (by which I mean SNCOs and junior officers) are more likely to understand quite a lot about all three areas. I always found the EAs in all three Services superb. But, reader8, you are right in saying very few would speak out, especially when (by definition) you're complaining about a VSO. Slightly easier for civilians, but MoD personnel policy has effectively got rid of any experience.

Yup, agree. One Pprune post can't characterise a whole system that's flawed from the guy on the 18 month ground tour deciding what to buy onwards. Plus the relative anonymity allows one to discharge both barrels.

I would say that it should be the job of the staff to educate the VSO. It's the job of the VSO to take the time to listen and understand when they are paid handsomely for the responsibility they hold. Too many complain about "too much detail" or "this is confusing" to give me a great deal of sympathy (although to be fair to them, it's often their staff laying that foundation for whatever agenda they may or may not have understood from the VSO, as I said, relentless politicians). These two phrases are dispatched by the VSO with a well practiced body language which either says 'tell me more' or 'STFU'. When it's STFU time, maybe they don't understand, maybe they don't want to. I think that if you can't tell the difference you still have problems. There are not many aircraft types and plenty of senior officers to go around.

I did occasionally see a DH simply listen to opposing viewpoints, allow both sides to frankly express views and then give homework and accept risk. It shouldn't come to that, but at given the, as you say, FFP nature of the whole thing it often did. Unfortunately, that behaviour was the exception not the rule.

Of course, depending on the structure of the acquisition the DH may not be able to do much anyway. Take P8 or F35, if there's something the Brits don't like, surely tough if there's a CBA to be done for a global fleet.

At least the front line knows, by-and-large, how to actually operate the thing. Civil aviation breeds experts, we generally don't. People can become so, but when they do the service can't take advantage of that

DE&S are supposed to be the answer, they're not. Again, rarely personal, just a system that doesn't work right.

If it all seams like a bit of a perverse characature, that's because it can be! Safety in terms of airworthiness is best achieved through compliance with recognised practice at the lowest level possible. When that doesn't happen, regardless of whether the problem is in materials used, designs embodied or redundancy provided, things go wrong answering the only question there is "but what does that mean".

oldmansquipper

4th Mar 2018, 10:02

This thread has been enthralling.

It seems that most posters (since the judgement anyway) are in broad agreement over the myriad causes of this tragic incident. We all understand there is/was 'something rotten in the state of Denmark', but what can be done about it? I really still cannot see the EA equivalents of today (SNCOs and Junior desk Officers) getting much joy from taking their concerns to their VSOs. I would love to be wrong.

IMHO, It is particularly poignant that the family of those poor people killed in the Grand Canyon helicopter crash recently are taking both the owners and the aircraft manufacturers to court over their failure to fit (if that's the right word) fire suppression to the fuel systems. I doubt that those responsible for that one will be able to 'hide' in this civil case.

So what, in your opinions, is an achievable 'way ahead' for UK Military Aviation, such that is left of it?

Answers in simple terms please - and not too many abbreviations etc ....

Shackman

4th Mar 2018, 10:28

oldmansquipper

4th Mar 2018, 11:02

I think some of the passengers survived the initial impact but suffered severe burns before or during egress and passed away later. It was a ticker tape headline on Sky meejah yesterday. Fuel suppressant issues feature heavily in the airworthiness discussions earlier in this thread.

oldmansquipper

4th Mar 2018, 11:08

OMS,

Just as a small aside - it is the fitting of a 'plastic' fuel tank that is believed to be the problem in the Grand Canyon accident: the same one fitted to all the DHFS squirrels.

And I agree, the thread makes fascinating (or should that be frightening) reading, particularly those inputs from Tuc, Chug 2 and Rigga, but also beggars the question 'why did MB roll over?' Or have I missed something

thanks I take your point on the plastic tank, however fuel suppressant discussions (and the lack of airworthiness action to implement protection) feature heavily in many of the posts in this thread. As for why MB rolled over? A very good question which also deserves an answer.

EAP86

4th Mar 2018, 20:32

So what, in your opinions, is an achievable 'way ahead' for UK Military Aviation, such that is left of it?

The MAA paid quite a lot of attention to adapting the civil regs to the UK military context but I feel they missed a fundamental point: in the civil system, the obligations are placed on those with the technical competence to make the right judgments. You have to use these people wherever they are to be found (irrespective of rank or organisation). Tuc has often drawn our attention to the CS process for gaining competence. While I agree wholeheartedly with his views, I doubt whether that process can be recreated in the medium term.

As for why MB rolled over? A very good question which also deserves an answer.

Just my opinion. Companies exist to deliver commercial success. Maybe MBA and their insurers decided that rolling over was the most effective way to return to commercial success?

EAP

NutLoose

4th Mar 2018, 20:59

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 for one am a great believer in keep it simple, I always have believed that burdensome legislation is not and never has been the way to go forward, It hampers those trying to achieve airworthiness whilst no matter how much paperwork you produce, those that failed to carry out such work previously are never going to do so simply because you have produced more rules.

In an ironic twist, EASA in their quest to make light maintenance "simpler" (read.. push responsibility off their shoulders and onto others) have pushed it on individuals to produce their own maintenance programmes for their aircraft, this has resulted in each individual aircraft of each individual type having a different maintenance programme, where as before you operated to a generic one size fits all that covered the basics, thus ensuring safety and a minimum standard. Now it is in my eyes cost driven.

reader8

4th Mar 2018, 21:00

I really still cannot see the EA equivalents of today (SNCOs and Junior desk Officers)

To be clear, each airframe has an EA, a Senior Officer who holds an LOA to allow him or her to act as such. These aren't SNCO or JO failures. The EA role is still staffed by somebody who should be SQEP to act as such.

oldmansquipper

4th Mar 2018, 22:04

To be clear, each airframe has an EA, a Senior Officer who holds an LOA to allow him or her to act as such. These aren't SNCO or JO failures. The EA role is still staffed by somebody who should be SQEP to act as such.

Sorry, I meant the guys at desk level who did the donkey work back in the day. I accept that the entire dept was the "EA (Engineering Authority)" IIRC ours was headed up by a SO1 (Wg Cdr) level who reported to the DD (a GC) by the time I left the first EA I was in, the Wg Cdr was in fact a Supply Branch officer. However, I recall going for guidance to one of my earlier Wg Cdrs (this time an Engineer) with a particularly 'difficult' issue, his response was, and I quote "oh, er, just keep all the balls in the air for a while, I am posted next month"

Clearly not SNCO/JO failures

Chugalug2

4th Mar 2018, 22:31

The problem was never the lack of regulations, they more than ensured that UK Military Airworthiness was fully functional and effective, provided they were implemented. And so they were, until the RAF equivalents of Pol Pot ordered that they be suborned, ie signed off as complied with but not implemented. Those trained and experienced engineers whose work it was to provide for airworthiness were now immediately faced with a moral dilemma, to defy what were clearly illegal orders or comply, with all that would entail. Those who complied ensured that there was an immediate break in the continuous process of audit that is the cornerstone of airworthiness. Without it even the most simple aircraft are rendered unairworthy and so the ACO gliders were grounded... sorry paused in consequence, albeit only eventually. Those who defied the order were hounded, persecuted, appealed, only then to have it confirmed by ministers that the orders were proper and that defying them was an offence. Eventually those square pegs were replaced by compliant inexperienced untrained non-engineers. The corporate knowledge was lost, the regulations pulped, and year zero heralded the infamous H-C Golden Period.

No amount of reinventing the wheel will avoid a repeat of this scandal happening again. You may well ask why RAF VSOs should want to subvert the airworthiness of their own aircraft. Of course, they did not. All they wanted was to release the historically ring fenced Air Safety monies to plug a gaping hole in the supply budgets, not caused by government cuts but by the ineptitude of RAF VSOs. The problem was not why but how, and it was all too easy as they outranked anyone who might seek to stop them, or reveal what had happened, or that certain resultant fatal accidents were airworthiness related. In short they did what they did because they could. Civilian Operators would no doubt do the same given half a chance, so they are denied it by having an independent regulator and investigator.

OMS, you ask what is to be done? I say do the same as the civilians. Nothing less than an independent regulator and investigator will suffice, lest history repeats itself (it oftimes does you know).

tucumseh

5th Mar 2018, 06:24

EAP86

I doubt whether that process can be recreated in the medium term.

Or long term, as it requires will. There is no longer a natural recruitment ground, as our workshops have been privatised. This contributes to the fact that most CS 'engineer' recruits don't realise they're skipping five grades. That's a lot of learning and experience missing. While they get on with their job, neither they nor their bosses understand what is NOT being done.

tucumseh

5th Mar 2018, 06:31

reader8

SQEPHas this term ever been defined by MoD? I know it defined 'inexperience' in the context of engineering programme manager (which, to a civilian, is something you do after EA, ILS Manager, Requirements Manager - or used to be!). 'Qualified' to, say, CEng, wouldn't have helped Flt Lt Cunningham. One thing that would have saved him was someone who'd listened to his first lecture on threaded fasteners and how to fit them, could read the regulations he was given a personal copy of, and passed a practical trade test.

dragartist

5th Mar 2018, 08:21

Sorry, I meant the guys at desk level who did the donkey work back in the day. I accept that the entire dept was the "EA (Engineering Authority)" IIRC ours was headed up by a SO1 (Wg Cdr) level who reported to the DD (a GC) by the time I left the first EA I was in, the Wg Cdr was in fact a Supply Branch officer. However, I recall going for guidance to one of my earlier Wg Cdrs (this time an Engineer) with a particularly 'difficult' issue, his response was, and I quote "oh, er, just keep all the balls in the air for a while, I am posted next month"

Clearly not SNCO/JO failures

When I joined SM65 (WPNS) sometime after you. My LOA was issued by the GpCapt. The WgCdr Stacker was out of the loop on all things Engineering. We tended to leave him sat in the corner orchestrating his release or managing his stocks and shares. The WOs who worked for me did not have LOAs.

oldmansquipper

5th Mar 2018, 13:37

IIRC, LsOA (letters of authority???) started to appear in the very early 90s as the 'EA' Morfed into a MDG, and then into a SA and IPT. My direct boss at the time was an Electronics S/L on retention. Excellent chap, very knowledgeable and eager to learn about my specialisation. On the other side of the office was a very capable and bright F/L. These two guys were very good (not all their predecessors had been) but I'm sure they were both frustrated as I was by the salami slicing that was going on. As you so rightly pointed out, WOs were never given 'delegated authority' and the responsibility for rubber and leatherware was delegated to them. So I guess they must have received their delegated LsOA shortly after I left but before SM65 moved up to Wyton.

I remember being surprised that final responsibility was being driven down to the level it was. It didn't make a lot of sense unless abrogation of responsibility on high was the aim all along. But what did I know?

NutLoose

5th Mar 2018, 13:50

One thing that would have saved him was someone who'd listened to his first lecture on threaded fasteners and how to fit them, could read the regulations he was given a personal copy of, and passed a practical trade test. I think that is rather unfair, If there is nothing to say the shackle should not be tightened down then the natural assumption would probably be to tighten it. The problem lies not with the person tightening it, but with the flawed design that allows it to happen in the first place.. I see poorly designed items day in day out and some actually assembled incorrectly by the manufacturers, because the design and the information are not there to prevent it.

Engines

5th Mar 2018, 14:47

Nutloose,

I'm really sorry, but I have to refer you back to my post 463 on this thread.

The RAFAT's arrangements for servicing ejection seats was, in my honest view, a shambles. No proper training, lack of experience, documented malpractices, all found by the SI. Add on to that a culture of abbreviated timescales, 'bespoke' routines, and an RTI that, again in my own view, should never have been issued, all combined to put this pilot in danger's way.

The over tightening of the shackle (and since when has cutting new threads into a bolt been 'accepted engineering practice'?) was just another link in the accident chain. Despite what I've said, I would not have harshly criticised the man who turned the spanner that day. I'd have started with his supervising NCOs, moved up the chain to the EngOs, asked the SEngO why his unit was being so cavalier with ejection seats, then asked the OC Eng what his safety and QA cell was doing to make sure that ejection seats (which are hazardous by their very nature) were being properly serviced.

And by the way, I wouldn't have asked very nicely.

The tragedy here is that, as Tuc as pointed out so many times, the main problem here wasn't lack of regs, or incomplete instructions. The main problem was a comprehensive failure to apply well known and extant regulations to control, manage and implement safe servicing of an ejection seat. And that failure took place within DE&S and the RAF.

Could the shackle design have been improved? Possibly. Were there shortcomings in the documentation? Probably. But if you give poorly trained, inexperienced personnel the responsibility for frequently disassembling and reassembling a safety critical item on an ejection seat, they you are creating a far bigger risk that MB ever did.

Best regards as ever to all those working so hard to keep our people safe,

Engines

NutLoose

5th Mar 2018, 15:05

I didn't realise he had rethreaded the bolt.

tucumseh

5th Mar 2018, 16:32

It is worth reminding ourselves that when Martin-Baker issued SIL704 after the accident, part of the reason was they were under new instruction from MoD to remove the assumption that RAF engineers would be adequately trained.

Hitherto, they had been instructed to assume a certain degree of training that would, for example, ensure maintainers didn't cut new thread and knew that the Drogue Shackle had to be free to move. The RAF Director of Flight Safety warned the Chief Engineer and ACAS about this very problem in 1992. That, maintainers were being held 'hostage to fortune'.

NutLoose

5th Mar 2018, 17:24

to remove the assumption that RAF engineers would be adequately trained.

Remind me never to fly in a service aircraft ever again. That is frightening in the extreme. Looking at the current course lengths they are under half the length mine was.

Talk about a worrying situation, no wonder crews are leaving in droves.

Rigga

5th Mar 2018, 18:12

So, I just looked up the definition of SQEP in today's MOD (MAA) MAA02: Military Aviation Authority Master Glossary Issue 6.1 :

Term: Suitably Qualified and Experienced Person
Abbreviation: SQEP
Definition: Intentionally Blank

Exrigger

5th Mar 2018, 18:16

Tucumseh:

SQEP requirements are littered throughout the RA 1000 regulations, depending on post, some more specific posts have them listed in a table, for example RA1003(1) & 1022(1) also RA 4945 has requirements for post but not utilising the descriptor SQEP:

https://www.gov.uk/government/publications/regulatory-article-ra-1000-series-general-regulations-gen

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/460556/RA4945_Issue_2.pdf

airpolice

5th Mar 2018, 18:24

Remind me never to fly in a service aircraft ever again. That is frightening in the extreme. Looking at the current course lengths they are under half the length mine was.

Talk about a worrying situation, no wonder crews are leaving in droves.

I think you might find the courses are even shorter than the timescales would suggest. There's a lot more team building and adventure training than in the old days. That, and all the fluffy stuff, eats into the time to learn a trade.

Mortmeister

5th Mar 2018, 19:41

Engines,

Spot on!

Regardless of all other actions, despite all the failures that caused the Ejection Seat to be activated; Flt Lt Cunningham should have drifted to earth on his parachute - surprised, but unharmed.

Regards
MM

EAP86

5th Mar 2018, 20:51

reader8

Has this term [SQEP] ever been defined by MoD?

I suspect not but I always thought it was not fully understood by many in the MAA. The nuclear industry use it extensively and its far more than just a term meaning 'competent'. There's a generic definition here https://en.wikipedia.org/wiki/SQEP but I think it misses the full scope of the nuclear usage.

EAP

NutLoose

6th Mar 2018, 01:16

BigGreenGilbert; He didn't "rethread" it, he cut new thread.I said re-thread because cutting a new thread can alter the dimension of the original bolt thread which you wouldn't want as it can effect the nuts ability to lock and weakens the bolt, as indeed lengthening the thread does, but hey ho, you can get none split dies that are designed to clean up damaged or bruised threads as in re-threading while not effecting the dimensions and can also be used to cut new thread..

and example of

https://www.grainger.com/product/CLEVELAND-Hex-Fixed-Die-20X681

..

tucumseh

6th Mar 2018, 06:26

BGG

I apologise if I wasn't clear. I don't agree with the definition of inexperience I mentioned. (Only having managed - not just worked on - and delivered 125 projects to time, cost and performance). It was and remains ludicrous, and I'd like to think most areas of DE&S don't apply it. Nevertheless, it was a formal policy, was applied, and is still cited. I mention this because I know the local Abbeywood MP/Minister once asked Min(AF) how widely this was applied and how many staff met the criteria, but MoD wouldn't reply.

I feel it is important to define SQEP for the purposes of airworthiness delegation, and technical and financial approval delegation. (All can only be given to engineers). Again, there are mixed messages from MoD/MAA. Correctly, it requires a degree of experience and qualifications, but in parallel continues to support those who self-delegated all three delegations - leading directly to many of the deaths discussed here.

I think honesty and integrity are equally important. One can be experienced and qualified, but a fraud and incompetent. Again, see the same deaths. We're not talking about scores of people. The same names crop up in most cases.

So, I think we agree. I don't like the term as it perpetuates the policy of dumbing down.

Regarding the pubs. Many are provided in the form of 'handouts' during training and, yes, you are right, they are not maintained. (As a matter of policy, so few are). But in this context (XX177) I'm talking about basic engineering that hasn't really changed for centuries. The AP that tells you one thread showing, not the 1.5 mentioned by MoD and HSE. (Apply that, and Sean Cunningham would be alive).

MoD has created a problem for itself by continually re-inventing the wheel. We lost our specialist Technical Authors (used to be around 600) and we now have contradictory regulations (e.g. 1.5 threads). Also, if the good book says to use a new stiffnut when loss of torque could lead to the loss of the aircraft, you really shouldn't need to spell out that this also applies to where loss of life could result, but the aircraft survive (e.g. this ejection). Note: stiffnut, not locknut, the term used by the SI. It's important to understand the difference when lives are at stake. And now that I've said this on MoD's Corporate Knowledge website, there will be a frantic re-assessment of said book and in a year's time a quiet amendment. As ever.

But, upon my first appointment as a Technical Agency (as you say, a new role, and requiring higher delegation) I was handed my personal copy of the two-volume Def Stan that anyone with airworthiness delegation should know backwards, that then sat on my desks for the rest of my career. If implemented, Sean Cunningham would be alive. (Just one of the layered defences in depth that broke down, long before he entered the aircraft). They were maintained, and our registry (sorry, showing my age) would come round and update it at each amendment. This standard was finally withdrawn in 2015, although staff had been told to stop using it many years before. It has never been replaced - D/Stan tried to update it many times, but weren't permitted. But the wise will still use it and, in fact, it still forms the basis of the Infantry's flagship programme whose aim is to reduce casualties. A noble aim, and perhaps the MAA should wander down and ask for an updated copy. Because, plainly, none of them have read it, never mind had to implement it.

ancientaviator62

6th Mar 2018, 07:20

Regarding the term SQEP when I was on the HEART team in 1997, the management epithet most popular at the time was 'tainted by experience'.
I found this a very curious way to do business

tucumseh

6th Mar 2018, 08:19

AA62

Yes, an oft repeated term at that time. It arose from CDPs' policy the previous year, that he did not want engineering project managers managing engineering projects. He announced 600 job cuts, just after everyone had moved from London. He was hated, and everyone I know had a little smile when Haddon-Cave dug a hole and shoved him in.

His problem was that the policy I mentioned earlier, new recruits skipping 5 grades, meant a huge disparity between staff at the same grade; so he chose to dumb down to avoid embarrassment. He should have been demanding that all staff satisfy grade minima. (Today, I'd say a mere handful in DE&S do). For example, I had two engineers of the same grade in one of my teams in 1997. One had airworthiness delegation and managed work that in other parts of MoD attracted sizeable teams. (He's still in, and one of the few). The other was minutes secy to a minor meeting, and entered data in a database. The latter was not to blame in any way, and in time became useful - but in a very narrow field, meaning he didn't meet minima. But the other was bored out of his skull, because he knew he was doing work beneath (what he considered, correctly) his paygrade. Equally, he was annoyed because the pay structure at the time favoured the inexperienced. This wasn't easy to manage, not least because Servicemen looked on aghast, as their system tends to avoid such disparity. Both OR and front line were given contact details if they had queries on any given subject, but all naturally deviated to the guy who knew how to solve the problem, even if not his job.

Exrigger

6th Mar 2018, 09:31

From the Nuclear SQEP description you have this:

and conversely suitably means suitably, not particularly well: the Office of Nuclear Regulation takes SQEPness to be broadly equivalent to the International Atomic Energy Agency concept of 'competence'

IAEA has defined competence as “the ability to put skills and knowledge into practice in order to perform a job in an effective and efficient manner to an established standard” ONR concurs with this definition, which is widely accepted within the international nuclear community. Other factors contributing to a person’s competence include the person’s prior experience, aptitudes, attitudes, behaviours, skills and qualifications.[2]

Within the MAA competencies are within RA 1002:

https://www.gov.uk/government/publications/regulatory-article-ra-1002-competent-persons

However I think the point being made is there may be some lower down that are considered SQEP/competent and fulfil the criteria laid down, it is some of the management, both military and civilian, who don't necessarily hold that same competency or knowledge of the subject matter required of the post they hold, 'jobs for the boys' springs to mind, and are averse to being 'shown up' by their more capable subordinates, so ignore/suborn/prevaricate/hide information to cover their backsides when things go wrong, these are the ones who are at the heart of the issue.

To fill gapped posts some incumbents do not always fill the regulated requirements of experience and competency for that post, so end up not fulfilling the due diligence for the task, totally innocently in most cases, which would appear to suit the management style described above.

As has been said before, in cases like this the Accountable Manager/Duty Holder is where the buck stops and when it goes wrong they should be standing in the court to explain why it went wrong under their watch, don't see that often with regard the military to date, so these threads will no doubt continue unless they sort themselves out.

NutLoose

6th Mar 2018, 10:16

Regarding the pubs. Many are provided in the form of 'handouts' during training and, yes, you are right, they are not maintained. (As a matter of policy, so few are). But in this context (XX177) I'm talking about basic engineering that hasn't really changed for centuries. The AP that tells you one thread showing, not the 1.5 mentioned by MoD and HSE. (Apply that, and Sean Cunningham would be alive).

MoD has created a problem for itself by continually re-inventing the wheel. We lost our specialist Technical Authors (used to be around 600) and we now have contradictory regulations (e.g. 1.5 threads). Also, if the good book says to use a new stiffnut when loss of torque could lead to the loss of the aircraft, you really shouldn't need to spell out that this also applies to where loss of life could result, but the aircraft survive (e.g. this ejection). Note: stiffnut, not locknut, the term used by the SI. It's important to understand the difference when lives are at stake. And now that I've said this on MoD's Corporate Knowledge website, there will be a frantic re-assessment of said book and in a year's time a quiet amendment. As ever.
The trouble here is overlap, the RAF and the UK always has had a standard of 1 1/2 threads showing, remember, go back 50 years and we were a, if not the leading supplier of aircraft to the World, and the British standard was 1 1/2 threads.
The problem comes when the US started to dominate the industry and their 1 thread standard came into play, the likes of Martin Baker as a global player will have produced their goods to fit the standards of what must be their largest market. The RAF are then in a position of do you teach the 1 thread or 1 1/2 thread standard and bearing in mind that up until lately some aircraft still in service would be using the stricter tolerances, then surely that is the one to teach ( or both), if a bolt is to be tightened to 1 1/2 threads showing but is tightened to the lower figure then the potential is there for a bolt to be undertorqued.. So I can totally understand why accidents like this happen.

A stiffnut is a lock nut, they are one and the same thing, just different terminology, similarly a cotterpin is the same as a splitpin... push bikes apart.

While in the RAF I was taught and still adhere to the principal to replace all used stiffnuts, that was not always the case civilian wise as you could check it still retained a rundown torque.

note.

Advantages of the all metal lock nut are heat and wear resistance. Military and aircraft standards allow this particular style of locknut to be reused up to 15 times, given that the nut will continue to provide some minimum specified prevailing torque (United States' Military Standard 'Mil Std' MIL-N-25027).

http://mgaguru.com/mgtech/restore/rt104d.htm

tucumseh

6th Mar 2018, 11:01

My trade training notes. AP3279, AL7, Feb 1970. Para 30 is of course qualified elsewhere by the instructions when to use a new stiffnut (see previous post). A locknut is different from a stiffnut, although commonly used as a generic term. Often the difference is unimportant. Here, it is. (The one at bottom right is used in the seat).

I agree with your point that the problem is inconsistency across training and pubs. My point is that anyone using the same training I had would have followed this and the shackle would have been free to move. And the evidence, revealed in the judge's remarks, confirmed maintainers at other RAF stations stated one thread.

http://i214.photobucket.com/albums/cc291/exploringtheblue/AP3279%20s1ch4_zpsu3mwlemh.jpg (http://s214.photobucket.com/user/exploringtheblue/media/AP3279%20s1ch4_zpsu3mwlemh.jpg.html)

http://i214.photobucket.com/albums/cc291/exploringtheblue/locknut_1_zpsbqprlybp.jpg (http://s214.photobucket.com/user/exploringtheblue/media/locknut_1_zpsbqprlybp.jpg.html)

tucumseh

6th Mar 2018, 11:18

Sorry, I should perhaps just clarify matters by saying all this is academic as far as the court case is concerned. The instructions issued by Martin-Baker to customers in the 1960s/70s/80s were:

‘Tighten nut until contact is made with Drogue Shackle. Do not torque. Verify that clearance exists between Drogue Shackle and the Scissor Assembly, and that the shackle can be freely rotated on the Scissor Assembly’.

Had this been followed, would Flt Lt Cunningham be alive? It may very well be that M-B didn't provide the warning in 1990, which was the basic of the HSE's sole charge. But very clearly they understood the issues and included warnings and cautions in their manuals. Their difficulty came when different customers wanted this expressed in different ways. So, just because the HSE said five other users were told in 1990, that doesn't mean MoD wasn't told in slightly different words that reflected its regs and training of the day.

Exrigger

6th Mar 2018, 11:24

RA 4266 refers to the use of self locking nuts, but as in the case of a lot of RA's it referes to the MAP-01 Chapter 6.15:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/350529/RA4266_Initial_Issue.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/577553/printablemap-01.pdf

Extract from Chapter 6.15:

General Rules
As a general rule, the male threaded portion and nut may be removed from the assembly and re-used more than once, the nut must meet the minimum run-down torque criteria detailed in each platform Aircraft Maintenance Manual (AMM) Topic 1 on each application and must achieve a minimum of 1.5 threads protruding beyond the nut when the final locking torque is achieved. For small stiffnuts of 6mm O/D and below, the run-down torque must be greater than that which can be applied with finger pressure.

Further generic instructions on the procedures that must be used for checking aircraft self-locking fasteners is included in AP 119A-0428-1 Chap 3 paragraph 7. An entry referring to these generic procedures must be included in each AMM.

tucumseh

6th Mar 2018, 11:44

Finger tight. Which hand? I'm right-handed but arthritis means my grip between thumb and forefinger is weaker. (This has many disadvantages). I do remember 'finger tight', for example when loosely assembling something so it doesn't fall apart, having partially dismantled it to gain access to another area. In any case, try tightening a philidas stiffnut finger tight. There'd be no threads protruding. The end of the bolt would be half way down inside the nut. Even 'finger tight plus half a turn', which is taught in some applications, wouldn't be enough. If by some chance you could overcome residual torque with your fingers, then the nut is scrap anyway.

But as I said, simply not applicable to a safety critical part that must be free to move. This all needs rewording.

What document does a maintainer have when working at the aircraft? Not RA4266. Nor Def Stan 00-970, as claimed by MoD & HSE. He has the AP (not written by M-B), his trade training (whatever that may be), common sense and engineering judgement.

Edited to add. After the accident, M-B issued SIL704, which said 'flush', not one or 1.5 thread pitches. As MoD (specifically the Service Inquiry/MAA according to the evidence) required this, why has RA4266 not been updated? Is this just applicable to Mk10B seats? To the RAF only? To all stiffnut applications? As the CAA promulgated this SIL, the world and his dog must now be thoroughly confused.

Exrigger

6th Mar 2018, 12:07

Edited to add. After the accident, M-B issued SIL704, which said 'flush', not one or 1.5 thread pitches. As MoD (specifically the Service Inquiry/MAA according to the evidence) required this, why has RA4266 not been updated? Is this just applicable to Mk10B seats? To the RAF only? To all stiffnut applications? As the CAA promulgated this SIL, the world and his dog must now be thoroughly confused.

And here lies the issue that this and other similar threads keep highlighting: the constant changing of technical information, regulations, reducing training has culminated in a confusing and contradictory environment that is counter productive to its concept of safety/airworthiness and the protection of life.

Will changing the rules and regulations again, make any difference, is there a will from those at the top to admit the erosion of safety/airworthiness has been happening, if they did, do they have the will and knowledge to make those changes, or will more accidents/loss of life have to occur, and more importantly someone in the military management to actually be held culpable and dealt with appropriately to get the message through.

Engines

6th Mar 2018, 12:56

Perhaps I can help a little to clarify matters here.

Whenever any maintenance was carried out on RN aircraft, the supervisor for that work was required to ensure that the person carrying it out had the required qualifications, training and publications available to do the job. Units and departments also took care to ensure that any work on a safety critical item was carried out by an experienced tradesman. One of the basic requirements of any tradesman, as well as supervisors, was to understand the way in which the system they were working worked. If required to dismantle and reassemble a drogue shackle, they would have been required to understand that shackle's function, how it operated, and the key checks to be carried out after reassembly. These 'competences' were checked on a regular basis for all ratings, using a rolling 'performance check' system that was mandated on all FAA squadrons and departments. In essence, the RN pursued a 'competency based' system backed up by active local quality assurance.

Due to their particularly hazardous nature, any work on ejection seats was specifically authorised to a few personnel who had also done a special 'seat safety course'. If at all possible, work on ejection seats at first line was avoided by returning the seat to the bay and replacing it with a serviced item. One of the main reasons the RN did this was because we knew that, having dispensed with a specialist Weapons trade, the 'Weapons Electrical' ratings we had were less experienced than their forbears. hence the special precautions that were taken. Now contrast that approach with what the SI established happened on the RAFAT, where inexperienced tradesmen, with no authorised training, worked in pairs on the aircraft, supervising each others' work, using handy pre-printed forms.

Sorry if I'm repeating myself. We can all go on as much as we like about how many threads should have been showing, what sort of nut was used, and what APs were being used, and who issued what warnings. The core issues with this tragic accident are (in my view) staring us in the face.

An RTI that wasn't actually required to make the seat safe was issued by the engineering authority, possibly at the behest of the operating authority - and apparently nobody involved in the process kept a single record of how that happened.

A safety critical system was being taken apart every 50 hours. By itself, that should have raised massive warning flags. However, once again, no records seeem to exist on how that risk was supposed to be managed.

The RAF failed utterly to ensure that the people carrying out this safety critical task had the experience, training or supervision required to make it safe.

The poor s*d who actually overtightened the shackle on that day had, by the time he did it, been comprehensively failed by a number of people. Not by the system - by people not doing the jobs they were given to do.

The solution to this sort of problem is not, repeat not, more regulations and more instructions. It's this - do what we're already supposed to be doing.

Best Regards as ever to all those who are doing the work for real at the coal face today,

Engines

EAP86

6th Mar 2018, 13:58

As the CAA promulgated this SIL,

Tuc,

a SIL is a MBA 'instruction' to all their non-MOD customers. Where contracted to do so, a DO will redraft the SIL into the MOD's required format. The same happens for export customers but where there is no contract, the operator receives the SIL anyway.

Where a civil operated ex-military type has a live ejection seat, the CAA can require compliance with the SIL before the will allow a Permit To Fly to be issued. In line with usual civil practice, I believe the CAA would treat the SIL as approved data requiring operator compliance without being "promulgated" by the regulator. If its really important from an airworthiness perspective, they can designate the content as an Airworthiness Directive.

Unlike the UK MOD approach, 'approved data' is issued mostly by the Type Designer.

EAP

tucumseh

6th Mar 2018, 14:22

EAP

I tried to keep it succinct. On 16 November 2011, MoD promulgated SIL704 by means of Urgent Technical Instruction/Hawk/34. On 17 November 2011, the Civil Aviation Authority reflected it in Emergency Mandatory Permit Directive (EMPD 2011-008-E), which notified users other than the MoD. Two years later, SIL704A was issued - same again.

Slow Biker

6th Mar 2018, 16:24

OMS and dragartist mention that the head of EA was a Wg Cdr stacker with no input to eng matters, these were raised to the Gp Capt. So, when the Gp Capt retired and was replaced by a CS with no eng LOD/LOA and no apparent interest, finance came first, higher level signatures were referred a Gp Capt in another PT. Then the Sqn Ldr head of AAES was posted and eventually replaced by another CS with no seat or indeed aircraft experience. Follow that up with the retirement of our PDS Officer, with his duties, LTC etc, handed over to the DOs. Add the distractions: preparing the case for seat maintenance remaining with the MoD rather than accepting a bid from MBA; constant efficiency and money saving drives and fending off the Army's bid to manage all explosive items, one can see where we are heading. I am not trying to justify anything, just adding to the plot.
Engines remarks that in his area a seat would be removed for any detailed work and swapped with a S item; surely that is the only way to do it. How on earth were RAFAT 1st line allowed to carry out a detailed RTI in situ.
Engines really hits the mark regarding knowledge and understanding of a safety critical system. A FJ sqn facing a summer of display detachments elected to 'train' an airframe snco to carry out Independent Checks on AAES, rather than send a wpns snco with the det. I have nothing against riggers, but a local training course would not imbue the individual with the depth of understanding needed to take on the responsibility of AAES Independent Checks. Our argument was dismissed. But on the same visit my faith in snco armourers was shaken. In discussion about independents with a wpns snco he ventured that to 'make sure it's done properly' he disconnects the PEC and reconnects it himself. He would not accept that by doing so he would invalidate the signatures of both the tradesman and the supervisor as well as his own. I could weep.
Phew, I've got that off my chest, it has been festering for a while. Now I can go back to working my way through the fascinating Pilots' Brevet thread.

NutLoose

6th Mar 2018, 17:19

A safety critical system was being taken apart every 50 hours. By itself, that should have raised massive warning fla

Yes, I know of one aircraft that there were issues with the wing attachment bolts and it was deemed acceptable to pull and inspect them every 100 or so hours until sense prevailed and they realised the were doing more damage to the spars carrying out the inspection than the damage the inspection was raised to address.

oldmansquipper

6th Mar 2018, 18:06

Nutloose.

At one point in my EA career, I recall over rotation of Tucano and Harrier (whatever happened to them?) harness Quick Release Boxes (QRB) became a hot topic. Generated by an 'Air incident' signal the problem did not degrade the performance of the box when holding the pilot into the seat ...but, understandably, it was considered a bit disconcerting when a couple of pilots managed to do it whilst strapping in.

Against our specialist advice, the 'dark side' of the office decided to issue a PWI (a UTI in old money?) and follow up SI calling for a check of the QRBs on each BF. IIRC, the check involved the BF crew, probably the plumbers, carrying out several trial operations of the box to see if the QRB could be turned beyond the normal locked position.

From what was initially a couple of arisings, the office was suddenly faced with multiple failures and, of course, many lost sorties. The dark side swiftly handed the problem back to 'rubber and leatherware' where we established that the increase in incidents was directly related to overenthusiastic tradesmen working the box until it broke.

But we digress....

Slow Biker

6th Mar 2018, 18:09

OMS - Sorry.

oldmansquipper

6th Mar 2018, 18:58

OMS - Sorry.

SB

I'm sure it wasn't just the Plumbers!!!

Nice honest post of yours earlier, BTW - and was that the "golden era" of which Tuc et al speak?

Engines

6th Mar 2018, 20:13

OMS,

Really good post, and you raise some very good points.

I was trained to be aware of the fact that the best way to really b****r up any system was to start disturbing it. Our servicing reviews in the 80s were always aimed at extending servicing intervals wherever possible. If you DID have to make a regular check on a system, you made sure that the check was as repeatable and non-intrusive as possible. I remember the QRB saga, and can add the RN's own saga with Sea King generator issues, where the damn things were coming out every 5 minutes as the problems mounted up.

One point I'd like to make, and I'm really sorry if my various blatherings have created the wrong impression. There never was a 'golden age', in my view. (I think this phrase first cropped up in the Haddon-Cave report). In my period going through from a callow youth to the giddy heights of a Commander, I saw plenty of errors, and made more than a few myself.

I lost good friends along the way, as well.

Luckily, I usually had bosses and subordinates who were not afraid to tell me I'd cocked up, and put me right. I was also fortunate to be in the Navy, where engineers were treated as an equal part of the team, and accorded respect by aircrew (once they'd earned it, of course).

I do think I was lucky in my timing, as we had the room to make decisions at a fairly junior rank, our concise RN engineering regulations were based on the principle of telling us what we couldn't do, not what we were allowed to do. We also had larger fleets of aircraft and more bases, which gave us all a better chance of getting the requisite experience as we moved through the system. We also had quite excellent technical Civil Servants (and contractors) working with and alongside us, sharing lessons and knowledge.

Last point. Whatever the system they have to work within, 'the youth of today' are absolutely excellent. The young engineers and aircrew I encounter are simply outstanding, and deserve our respect and support as they serve their country.

Best regards as ever to all our service personnel,

Engines

Chugalug2

6th Mar 2018, 21:44

OMS:-
was that the "golden era" of which Tuc et al speak?

The "Golden Period", refers to the Haddon-Cave Report in which he bizarrely labelled the early 90s thus, when they were in fact the very years that the UK Military Air Safety System was being plundered, sabotaged, and rendered utterly dysfunctional by certain RAF VSOs. He then misleadingly shifted the deterioration of airworthiness provision to later years. Now how might he have got hold of that idea, when he had evidence before him as to the chronological sequence of this scandal? That the MAA uses the Haddon-Cave Report as its foundation says it all. Isn't there a parable about houses and sand?

Engines, I acknowledge the woeful behaviour of the RAF from top to bottom as highlighted by the SI and yourself in this fatal tragedy. Your pride in your own Service is understandable and commendable, but might I gently point out that the crisis in UK Military Airworthiness involves all UK Military Aircraft of whatever Service?

One of the threads on this very forum concerns the loss of seven RN aircrew in a mid-air collision between two Sea King "baggers" in poor visibility. They were fitted improperly with HISLs which had simply replaced the existing ACLs without trial, contrary to regulations. In the very conditions they were flying in the forward HISLs caused pilot glare and it was the practice therefore to switch them off, contrary to regulations. I only instance this as yet another example of when the lower orders are faced with a fait accompli from above then they have to make do as best they might. The scoundrels are those who place them in that position. The scoundrels in this scandal were RAF VSOs. Let us keep our eyes on that particular ball!

oldmansquipper

6th Mar 2018, 22:14

Thanks Chug.

From what slow biker was saying, the run down he so graphically describes was roughly the same period (90s).

OMS

airpolice

6th Mar 2018, 23:13

The scoundrels in this scandal were RAF VSOs. Let us keep our eyes on that particular ball!

I make an observation, no more:

I am not in any way, subtle or disguised, trying to incite anyone to do anything. I say that, not with a view to avoiding a prosecution, but simply to highlight the open nature of my question.

From my reading of this, and many other posts on similar topics, I feel there might well be a desire, indeed some benefit to be had, from..... us... as a community... as it were... moving away from discussing VSOs and the MoD as faceless entities, and actually naming the people, not the positions they held, when this series of (scandalous / treasonable / careless / reckless) acts were carried out, and indeed, commanded.

I say again, I am not suggesting that we name them on here, I am simply asking, am I the only person who thinks that we should?

glad rag

6th Mar 2018, 23:32

"In discussion about independents with a wpns snco he ventured that to 'make sure it's done properly' he disconnects the PEC and reconnects it himself. He would not accept that by doing so he would invalidate the signatures of both the tradesman and the supervisor as well as his own."

Oh yes, there was me thinking that little dit was the property of the (ex) REME supervisor....how do you check the flying control electrical connectors for correct assembly, connection, and auto locking? You take them orf and on again yourself, Sah!!

tucumseh

7th Mar 2018, 00:08

airpolice

...and actually naming the people, not the positions they held, when this series of (scandalous / treasonable / careless / reckless) acts were carried out, and indeed, commanded.

I'd say they have been, repeatedly, on the Mull of Kintyre and Nimrod threads. Haddon-Cave praised some of them. They've been named elsewhere in print, and shortly will be again. Had he published the evidence Chug talks of, H-C would have had to name and shame them, instead of those he did.

Glad Rag

how do you check the flying control electrical connectors for correct assembly, connection, and auto locking? You take them orf and on again yourself, Sah!!

See Chinook FADEC connectors! In-flight servicing to check their security, instead of selecting the correct type/locking in the first place. Barking.

Engines. Sea King generators. Only time I've seen 24kVA generators run at 23.96; and that was with a 3rd fitted. And they complained they couldn't get more EW kit. Perhaps a 40W bulb.

Chugalug2

7th Mar 2018, 08:05

airpolice:-

I am not suggesting that we name them on here, I am simply asking, am I the only person who thinks that we should?

It all depends on your imperatives. Mine, as well as others who post here, is the very urgent reform of UK Military Airworthiness and Air Accident Investigation in order to avoid future avoidable accidents and deaths. Even if that is achieved the UK will still be left with the mess that is the MOD, and from which this scandal erupted. That is up to the UK to resolve in its own time. Personally, I won't be holding my breath.

As tuc says, a lot of what you seek is already in (e)print. Here is a link for starters:-

https://www.amazon.co.uk/Their-Greatest-Disgrace-campaign-Chinook-ebook/dp/B01J1YVRH0/ref=tmm_kin_swatch_0?_encoding=UTF8&qid=&sr=

and, as he added, more on its way!

oldmansquipper

7th Mar 2018, 11:16

airpolice:-

It all depends on your imperatives. Mine, as well as others who post here, is the very urgent reform of UK Military Airworthiness and Air Accident Investigation in order to avoid future avoidable accidents and deaths. Even if that is achieved the UK will still be left with the mess that is the MOD, and from which this scandal erupted. That is up to the UK to resolve in its own time. Personally, I won't be holding my breath.

As tuc says, a lot of what you seek is already in (e)print. Here is a link for starters:-

https://www.amazon.co.uk/Their-Greatest-Disgrace-campaign-Chinook-ebook/dp/B01J1YVRH0/ref=tmm_kin_swatch_0?_encoding=UTF8&qid=&sr=

and, as he added, more on its way!

Copy on birthday wish list. 😊

dragartist

7th Mar 2018, 12:37

Copy on birthday wish list. 😊

And all the profits go to charities not in to Mr Hills pocket.

dragartist

7th Mar 2018, 12:51

SB

I'm sure it wasn't just the Plumbers!!!

Nice honest post of yours earlier, BTW - and was that the "golden era" of which Tuc et al speak?

The Army Air dispatchers were just the same. Rag Packers at AFPSU would sign off and stamp up the old 28fts.
Depending on SPM (Supplies Proceeding Men) the Despatchers would ope the pack add a week link between the static line and Apex and recluse the pack without signing anything.

Dragartist made himself unpopular when he found out, insisting that the Despacther signed for the maintenance. Of course they were not Authorised to do this. Years ago they even packed the supply drop parachutes. We had several maldrops where the finger was pointed at the rag packer.

oldmansquipper

7th Mar 2018, 14:06

The Army Air dispatchers were just the same. Rag Packers at AFPSU would sign off and stamp up the old 28fts.
Depending on SPM (Supplies Proceeding Men) the Despatchers would ope the pack add a week link between the static line and Apex and recluse the pack without signing anything.

Dragartist made himself unpopular when he found out, insisting that the Despacther signed for the maintenance. Of course they were not Authorised to do this. Years ago they even packed the supply drop parachutes. We had several maldrops where the finger was pointed at the rag packer.

Imagine if you will, a Jaguar Sqn in Germany at the height of the Cold War. A scarlet safety thread break tie on the parachute flap closure pin has been found broken on AF. It is shift change and anyway probably too difficult to call out the duty squipper to rectify it (and complete the necessary paperwork on those lovely pressure sensitive forms of course) The simple solution was to get the armourers to do it (after all they work on seats, don't they?) No problem ...until armourer detailed realises he had no scarlet thread. Still No problem 'cos he had some locking wire in his pocket....

Luckily, a bright FLM (yes there were plenty of them!..bright ones I mean) prepping the jet for flight next day, queried the shiny wire where red thread should be.....

Caused a bit of a flutter in the dove coot, that one...

NutLoose

7th Mar 2018, 14:57

Imagine if you will, a Jaguar Sqn in Germany at the height of the Cold War, Wing Commander checking out his jet finds the drogue chute disconnected behind the flaps in the headrest.... Queue the bloody SIB questioning everyone, never did get to the bottom of the how, why or sadly, possibly who!

Rigga

7th Mar 2018, 20:50

After the accident, M-B issued SIL704, which said 'flush', not one or 1.5 thread pitches. As MoD (specifically the Service Inquiry/MAA according to the evidence) required this, why has RA4266 not been updated? Is this just applicable to Mk10B seats? To the RAF only? To all stiffnut applications?

Tuc,
I know that you know, but just to clarify to some that may not know...The M-B SIL is "Approved Data" and is written by the OEM giving particular information and/or instructions for a specific issue on a specified item. As such, the SIL takes precedence over any general standards and practices laid down in documents like MODs RA's or, for civil aircraft, AMM Standard Practices.

roving

9th Mar 2018, 19:23

The Official Transcript of the Judges remarks when passing sentence are now posted on the Judicial website and found on this link.

https://www.judiciary.gov.uk/wp-content/uploads/2018/02/sentencing-remarks-mrs-j-carr-r-v-martin-baker-lincoln-crown-court-23022018.pdf

dragartist

11th Mar 2018, 10:23

BruisedCrab

11th Mar 2018, 10:48

The judiciary must consider and decide using all evidence presented by both prosecution and defence. Any information not presented by prosecution or defence is not evidential and must not be considered without exceptional reason.

If people wish information to be considered, it must be given to either the prosecutor or defender (who will share it if relevant).

Heathrow Harry

11th Mar 2018, 11:01

Correct - I was on Jury Duty once and we asked the Judge why no-one had produced notes of a telephone call to the Police - he said pretty much what Crab said - if it isn't put forward as evidence you are to assume it doesn't exist and/or is not thought to be relevant

tucumseh

11th Mar 2018, 11:42

The 'unsolicited evidence' (proving MoD knew of the risk of over-tightening before 1990, and of the mitigation that eliminated it altogether), was provided to the judge, HSE and Lincolnshire Police. MoD had denied knowing of this at any time to 2011. The charge and judgement were based on this false premise.

As she said, the judge chose not to read it, but passed it to the HSE for comment - specifically asking about disclosure of evidence. (MoD had denied the existence of the QinetiQ report that formed the bulk of this 'unsolicited evidence', and had even briefed Philip Dunne MP to say in Parliament that MoD knew nothing of the alleged content).

The HSE replied (and this is in writing) that the evidence (of innocence) was irrelevant, although of course they didn't say 'of innocence'.

Thus, the judge was seriously misled (by omission), and many of her remarks are tainted by not having read, or been advised by HSE of, this exculpatory evidence.

In furtherance of their stated strategy of not upsetting MoD, it would appear (again, HSE's statement) that Martin-Baker concurred. Plainly, the company didn't think it irrelevant, but chose not to use it in their defence. That is, they took the hit.

The judge's remarks make if clear (at least to me) that she understood something was very wrong here, and she makes a point of criticising the fact that vital evidence was not put to her, due to the guilty plea. However, it was, but she didn't read it.

airpolice

11th Mar 2018, 11:54

The judge's remarks make if clear (at least to me) that she understood something was very wrong here, and she makes a point of criticising the fact that vital evidence was not put to her, due to the guilty plea. However, it was, but she didn't read it.

There is a process for evidence to be presented to the court. That process was not followed.

airsound

11th Mar 2018, 12:07

I'm sure you're right, airpolice, when you sayThat process was not followedBut where expert opinion not directly connected to the presentation of the case holds factual evidence, how should they get that process followed? It seems that the principle actors, prosecution and defence, were able to class that evidence as irrelevant without any possibility of redress, even from the judge.

airsound

tucumseh

11th Mar 2018, 12:17

airpolice

What process was not followed? The police were told, and they (I believe) are obliged to pass evidence to the prosecution. They didn't. The prosecution were advised. The slightly unconventional direct approach (to the judge's clerk) was forced by the late plea, and the knowledge that vital evidence would remain concealed. The judge did not complain, perhaps content that it had been sent to the prosecution; which she did anyway.

airpolice

11th Mar 2018, 12:54

In practical terms, the parties involved have got away with it.

A simple fine, paid for by the company from their massive reserves, and the ability of their sales people to openly tell existing and future clients, that MB took one on the chin to spare the client.

Where, as in this case, the crown decides not to present evidence to the court, the court must not go looking for it. Every player has their part, and each must do their own. Shortcomings (to be kind to them) on the part of the Police & Prosecution, are not matters for the public to resolve. Tragic isn't it?

They all get to sweep this under the carpet. I suggest that anyone who is really concerned about this should subscribe to Private Eye and read, every two weeks, about the eye watering waste of public funds, and abuses of process happening all the time.

I know that in this particular case, we are talking about the death of a fellow pilot, but the same scandals that keep that from being addressed, keep everything else under wraps as well.

If you don't like the fact that the Judge was not able to consder the evidence, then complain to your MP, that's how the system is supposed to allay your fears. An independent judiciary however, must (they say) be protected from political interference. So your MP can't change what a Judge decides to do or not do. You don't get to vote for Judges, only Judges do.

On a local level, even if everyone in your village, town, county, decided that they wanted stronger sentencing for offenders, you can't get that. The courts are independent of the elected representatives of the people. Remember the people? Those who suffer at the hands of criminals. Those people who know what they want to see happen to the bad guys.

You can lobby your local Councillor or MP, (who can't do anything about it) but whatever you do, don't try to lobby a Magistrate, Sheriff or JP. That's a different offence entirely.

The independent (there's that word again) judiciary, are protected from your interference, by law.

On the other side of the Atlantic, there is a big country with plenty problems of it's own, but they do get some things right. Particularly the process of voting for Judges. Where a court is not dishing out the sentences that a community wants to see, the voters have a chance to make their displeasure felt.

With the passage of time, this event will be consigned to a false history, like many others.

He died because his parachute failed to open.
The police helicopter in Glasgow crashed because it ran out of fuel.
ZD576 hit the ground because the were flying too low.
XV230 crashed because it caught fire.
Titanic sank because it hit an Iceberg.
The American civil war was about slavery.

Time passes, most people forget, more people die.

That's just the way it is.

Tucumseh, the process is that the Prosecution lay out their case before the court, and the Defence do their best to refute the allegations. We simply cannot allow the public to be shouting from the sidelines.

The irrefutable truth of what they are shouting, is not, legally, relevant.

tucumseh

11th Mar 2018, 15:03

Airpolice

Thank you, and what you say is of course true.

But there have been exceptions. In the XV230 case, Des Browne had the integrity to, in face of MoD denials and lies his junior Ministers, order the Nimrod Review. The legal establishment did its best to protect MoD, but there was a result of sorts.

Likewise, Liam Fox had the integrity to keep the promise to set up a Review, and Lord Philip accepted ‘third party' evidence that, yet again, MoD lied.

The Coroner accepted ‘third party’ evidence in the XV179 case – proof that MoD had lied about when it knew of risk mitigation, which is the central point on XX177. Here, MoD has learned, and withheld the SI report until after the Inquest, so denying the court and family independent expert advice.

The families involved might consider these successes in isolation, but if the truth was heard in court, the likes of Mr Cunningham would surely be asking why the same old failings had not been corrected, even after these Reviews.

I believe that, when sentencing, a judge is required to consider aggravating factors, including:

· Cost cutting at the expense of safety
· Deliberate concealment of the illegal nature of an activity
· Poor health and safety record
· Falsification of documentation

In this case, all were committed by MoD, not Martin-Baker. And, importantly, repeat earlier failures. That’s not just my opinion. It is fact, set out by the above Reviews and/or the RAF Director of Flight Safety. Mrs Justice Carr may have been entitled to ignore third-party evidence. She was certainly misled by both defence and prosecution. But she did not mention consideration of these aggravating factors.

I still wonder what would have happened if Haddon-Cave had heard the case last year, as planned. He would have looked utterly stupid if he overlooked the lack of a Safety Case Report. And I’m pretty sure the MAA wouldn’t have been so keen on their man being HSE’s ‘star witness’.

airpolice

11th Mar 2018, 22:33

But yet, the crown has not put anyone from Mod in the firing line.

A blind man, running for a bus, could see that there are people, not jobs, who need to be on trial here. It's never going to happen.

Everyone seems content to blame the MoD, as if the building was making the decisions, when in fact they were made by people who are now living the good life, on serious pensions.

Just think of the legacy this leaves us with. Why bother doing it right? They never come after you anyway.

Chugalug2

11th Mar 2018, 22:40

Air Police:-
In practical terms, the parties involved have got away with it.

The "parties" were just the bit players to the elephant in the room, the MOD. It is the MOD that has got away with it, yet again.

Its apologists will once again be congratulating themselves on a hand well played, and thus perpetuating the cover up.

As long as the cover up continues Military Airworthiness remains broken.

As long as it is broken avoidable accidents continue.

The more they continue then the needless deaths go on happening.

And all because of a hand well played...

tucumseh

12th Mar 2018, 04:45

airpolice

Everyone seems content to blame the MoD, as if the building was making the decisions, when in fact they were made by people who are now living the good life, on serious pensions.

You made this point last week, and you are correct. It was also pointed out that those who initiated the quite conscious rundown of airworthiness management have been identified. That publication asks the question 'Who or what is MoD?' and a decision was taken to avoid naming anyone below 2 Star, for stated reasons. I think that correct, given the available evidence and imperative.

To name individuals, publishers tend to require written, irrefutable evidence (and I think it only right to apply this to pprune). Accompanied, ideally, by these people putting themselves on record in the media and, if possible, recordings of this. On Mull of Kintyre we had all of this evidence, so no problem.

In this case, some names have been released - read the Inquest reporting from 2014. But I would certainly never repeat them, because everyone knows MoD would never allow someone in the witness stand who actually knew anything. Yes, we heard from one chap who insisted - probably truthfully - he'd never been told not to over-tighten the Drogue Nut. But he was a diversion. We never heard from his seniors as to why he wasn't trained; not just in how to fit a nut, but in how the device worked in the first place. Or their seniors, who decided to change the seat maintenance policy without ensuring training and pubs were updated. Or their seniors, who issued a directive that pubs and training were not to updated, as it was a waste of money. Or their boss (suddenly, singular) who issued the policy to waste the money, that made paying for this work difficult. Very quickly you get back to the same people who were named first time around; and whose policies begat Nimrod, C-130, Sea King, Tornado and all the other avoidable deaths. These are not sh*t happens deaths. Their root causes were predictable, predicted, notified (often years in advance) and ignored. The names of those who ignored these direct, face-to-face warnings, backed up by written warnings, are very well known and already in the public domain.

To me, the original legal failure in this case was that of the CPS, who decided that MoD's admission was not sufficient grounds for prosecution. When it admitted serious offences in the SI report; repeated from previous cases? The prosecution of M-B was a diversionary side-show. Expect a few names from the HSE in a future Honours List!

falcon900

12th Mar 2018, 09:32

Given MB have plead guilty, might there be scope for civil proceedings by the victims family?
A further ordeal on top of an already terrible ordeal for them, for sure, but no scope for the two sided in the trial being "hand in glove" .....

EAP86

12th Mar 2018, 10:06

Given MB have plead guilty, might there be scope for civil proceedings by the victims family?

There would only be proceedings if the claim was contested. MBA's insurers will have factored this into their considerations.

EAP

tucumseh

12th Mar 2018, 10:26

Falcon900

An interesting proposition. I wonder if some legal minded contributors could say if this could go ahead given MoD admitted liability and settled with the family before the Inquest? My opinion of this is that MoD knew what was in the SI report and wanted it settled, before anyone realised the extent of the offences committed. I also think, at that time, MoD didn't believe for one minute that someone else would be blamed. Their guilt was so obvious and openly admitted, and the judge made it clear she was completely baffled by M-B's guilty plea.

Edit - EAP got in first, but it doesn't change my post.

roving

12th Mar 2018, 11:12

Addressing the question of compensation, it is in England & Wales governed by legislation.

https://www.legislation.gov.uk/ukpga/1976/30/section/1A

Where a claim arises consequent upon a fatal accident caused by the fault of a third party or parties, there are three elements:

(1) Damages for "Bereavement" fixed by law. It is currently £12980 -- it may have been a lower sum in 2011.

(2) Funeral Expenses.

(3) Damages awarded to those financially dependent on the deceased at the date of his death. That is a slide rule exercise. A percentage of the diseased annual earnings is assumed to reflect the diseased's contribution to maintain those financially dependent upon him. Widows not in employment and children being obvious examples. The rule of thumb when I dealt with such cases, was two-thirds of the diseased's net income. That sum is then multiplied by a number set out in a table reflecting the diseased age, the dependent's age and the current yield on 10 year Gilts.

The hard and fast rule in England and Wales, is that fatal accidents are far cheaper for the insurers of the third party held negligently responsible than, for example, causing serious and permanent disability.

In a fatal accident case where any of the dependents are children, i.e. aged under 18, any settlement, including the sums apportioned for the children, has to be approved by the Court.

There can be only one settlement!

A settlement may not preclude the third party who has paid out, later seeking to recover a contribution from another party also considered responsible. There may, however be costs implications for bringing any separate claim. An added complication is that there are strict time limits for claiming a contribution. I may be wrong but I have a vague feeling it is (or was) 2 years.

Chugalug2

12th Mar 2018, 12:06

Roving, the problem with this tragedy is that it represents merely the tip of an iceberg which has accounted for 74 deaths in military airworthiness related fatal accidents featured in this forum alone. Airworthiness for which the MOD by itself or via its subsidiary authority is responsible. The real death toll is probably many times higher. By presiding over this farrago of a trial, the judge allows the iceberg to carry on the carnage unencumbered. Given the renowned independence of the judiciary, frowned upon by airpolice (though I am not so convinced), surely she could have ordered a mistrial if she were beset by the doubts her remarks seem to imply?

Having read her remarks, as a professional do you find they raise more questions than they answer?

roving

12th Mar 2018, 12:37

Going back some weeks, I commented "rather her than me".

This is an unusual case before the Crown Court.

1. The only punishment (sentence) available was a fine.

2. The "defendant" was a highly respected company.

3. In the background was the Government Ministry with responsibility for the safety of Royal Air Force. For reasons I set out many moons ago, they could never have been a "defendant" by reason of Crown Immunity.

4. MB admitted guilt on the narrow basis that it knew that if the nut was overtightened it could cause the very event which happened. MB accepted that it should have given formal written advice to the MOD/RAF of that risk. The High Court Judge sentenced on that basis.

5. Because the MOD could not have been a defendant, the question as to whether it in fact knew or should have known of the risk, irrespective of whether MB informed them, was for the purposes of this case, irrelevant. Why? Because MB owed the deceased pilot a duty of care, and two wrongs do not make a right.

If MB had, as it originally intended, maintained its "not guilty" stance, no doubt it all would have come out in the wash. But for reasons we can only speculate about MB changed its plea to guilty. So, as often happens, there is a feeling that the outcome is not satisfactory. But there is nothing that the Judge could have done about that. She had to deal with the Guilty plea before her, not speculate on what may have come out in the wash, had there been a trial.

POBJOY

12th Mar 2018, 16:17

On the basis that those with knowledge of the 'complete situation' also know that the wrong company was being tried; MB (no doubt after a very careful review) took a 'commercial decision' to limit the ongoing 'open wound' situation that a major investigation would have started.
At the end of the day the British public (or media) are not seemingly outraged by all this and the failings of the RAF/MOD/ RAFAT, is not something that sells more media.
MB would have ended up having to expose its 'customer*' and its* lack of attention paid to a very important and highly technical piece of survival equipment, and at the same time try to protect its name from being dragged through the process which was not of their making.
However what surprises me is that their legal team did not manage to convince the HSE that MB was not at fault and therefore the case was not at all in the public interest as the real culprit was the Government equipment user in this case.
As far as the 'Man on the Clapham omnibus' is concerned MB make excellent survival equipment, and the RAF are pleased to use it. I would have thought the HSE would be better tasked with dealing with the appalling state of many road surfaces and associated incidents, plus the ongoing deaths at rail crossings that still continue.

Heathrow Harry

12th Mar 2018, 16:21

If we want something done the only answer is a "Crusade" in a newspaper - pref the Torygraph but the Wail can get very dirty

The Politicians listen to no-one else................

Red Line Entry

12th Mar 2018, 16:29

So if MOD is culpable, why has the HSE not issued a Crown censure (as they did for the SAS deaths in the Brecon Beacons)?

tucumseh

12th Mar 2018, 18:15

RLE

I think the answer, or much of it, may be in roving's reply. The HSE are on record as saying evidence that MoD knew both before and after 1990 is 'irrelevant'. The exam question was - did MB provide a piece of paper in February 1990. MB admitted it didn't. The fact it wasn't required to (!) was also deemed irrelevant. (That's a longer explanation, and about zero people in MoD today could explain it. I'm a dinosaur, and still had to check with someone much older to get the details right in my head. He was down as a witness, but.....).

Another factor might be that, for all practical purposes, this was a joint HSE/MoD prosecution, as their main witness was a (now retired) MAAIB investigator. I was really looking forward to him being asked if he thought safety cases 'irrelevant', as well as evidence of innocence. (It's all in the SI report. They call it 'non germane'). But HSE have behaved so appalling, they may very well surprise us all with a censure. (They were asked, but didn't reply).

dervish

17th Mar 2018, 10:49

The fact it wasn't required to (!)

Tuc, I had to rack my brains but I reckon you're right. I'd like to hear MOD's response.

Chugalug2

18th Mar 2018, 10:54

RLE:-
So if MOD is culpable, why has the HSE not issued a Crown censure (as they did for the SAS deaths in the Brecon Beacons)?

A very good question. And why was MBA charged with an offence for not notifying MOD of the dangers of overtightening of the shackle bolt if they were no longer obliged to? Why did they plead guilty instead of producing evidence of their innocence and of MOD culpability? So many questions...

Distant Voice

19th Mar 2018, 11:19

According to the 2002 QinetiQ report the 'scissors' shackle mechanism was replaced on the Tornado seat with a GS drogue bridle release system because of a failure of the MBA trial in mid October 1998. The judge failed to mention this fact in her summing up. In fact she gave that impression that MoD had the gas shackle mod fitted out of the kindness of their heart, by stating, "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 inservice ejection seats, with the exception of the seats in the Hawk aircraft." The judge also failed to establish why the Hawk seats were not modified.

Had the judge gone down the "why did MoD have the gas shackle fitted to the Tornado seat?" route, the QinetiQ report would have been revealed and with it MoD knowledge that the 'scissor' shackle could jam. In my opinion the judge turned a blind eye to the report, and in doing so failed the Cunningham family and the general public.

DV

Just This Once...

19th Mar 2018, 11:48

Or, as said earlier, the gas shackle modification was not introduced into MoD service as a result of a manufacturer identified hazard with the original shackle. Equally I am not aware that MB proposed the gas shackle modification to any foreign user to resolve a safety issue with the original design. I do not think a civilian AD was raised for the civilian operators of ejection seats fitted with a scissor shackle either.

Returning to the original flawed design, it can be resolved (and was) by a simple and cheap bolt change. There has been no panic upgrade to gas shackles as a result of this issue; the problem was a single-point safety critical failure in the original shackle and bolt design. If MB had gripped the issue when identified 2 or 3 decades ago the old bolt design would have been withdrawn and all seat users would have received a modified retaining bolt. As we learned, MB was still providing this flawed part to multiple customers up to and shortly after this terrible incident.

Of course, we should not forget the safety pin that, when inserted, may not actually make the seat safe, or the firing handles effectively becoming a hair trigger, or the man sep handles being fatally ‘live’ when the seat is still in the aircraft, or a seat design change leading to a seat coming adrift and killing its occupant, or QRFs that can inadvertently release the occupant post-ejection and I could go on... Not all was well in MB’s safety process and things had to change.

tucumseh

19th Mar 2018, 15:22

JTO

As the 'quality of design' allegation was dropped, the only charge related to M-B not providing a technical bulletin in February 1990. Most of the issues you mention did not form part of the case. The media conveniently ignored this, citing the now discredited comment by the Coroner that the seat firing handle design was 'entirely useless' (and then disingenuously applying it to the whole seat).

The HSE deemed it irrelevant that M-B had provided the information both before and after 1990. What is the significance of the 1990 date? (I don't know). Perhaps the HSE did a trawl through records and said 'Ah, you didn't send it in Feb 1990'. But I don't see a raft of other customers who didn't get it then, including the US, taking issue. Perhaps because, like MoD, they already had the information, but had actually kept a copy and placed it on the internet for anyone to see. I didn't see the HSE quoting this information, which if followed would mitigate the risk of pinching the shackles (unless someone ignored both the instruction and their training and over-tightened the nut).

Poor training, and ignoring what training was given, has led to many more accidents than this. What makes this one different? Could it be that the high profile user makes it a good story for the HSE? Telling the judge that first hand witness evidence that the information had been provided was 'irrelevant'? I know who I'd have in the dock.

Distant Voice

20th Mar 2018, 10:59

In a 2015 Air Commodities 'Safety Assessment Report For Emergency Escape Parachutes', which cover types GQ1000 and GQ5000 it states that, "All parachutes have a 500ft minimum operating altitude". If that is the case how is it possible to use these 'chutes with zero/zero MB seats, when the maximum altitude achievable from a ground level ejection is only around 300ft, with rocket assistance?

DV

oldmansquipper

20th Mar 2018, 11:30

Good question, well presented, deserves an answer.

Perhaps it refers to other installations (static seats etc)?

Of course Ejection seat installations will have been subjected to comprehensive qualification test programs to prove (or not) whatever the system in a particular installation is. The parachute DA will undoubtedly have bought in to those tests, and I should think they had their own set of parachute installation QTP.

Perhaps PPruner "dragartist" or someone from Survitec (Maufacturers of GQRange) may wish to comment?

EAP86

20th Mar 2018, 12:30

walbut

20th Mar 2018, 12:35

DV

The 500 foot minimum operation altitude must have associated with it a horizontal and vertical speed. Perhaps the 500 ft is based on zero speed in both directions, in which case it is the acceleration of the man and seat downwards under gravity that generates the energy required to inflate the parachute.

In the case of a zero zero ejection, while the seat is moving upwards under the force from the rocket motor, the drogue gun fires and when the drogue chute deploys it rotates the seat around so that the crewman is moving upwards, feet first. When the scissor shackle releases from the seat and the main chute deploys, the occupant and seat are still moving upwards. In this case it is effectively the inertia or kinetic energy of the seat moving upwards that provides the energy to inflate the chute, which is partially if not fully inflated when the occupant reaches his/her apogee at around 200 -300 ft depending on weight.

I cant remember all the timing details. However if you want more information, there is an excellent little book called Engineering for Life by John Jewell that I acquired many years ago courtesy of Martin Baker and I 'borrowed' one of our office copies just before I retired. It might have been updated since ours was published in 1979.

Walbut

hoss183

20th Mar 2018, 12:50

oldmansquipper

20th Mar 2018, 14:17

Distant Voice

20th Mar 2018, 16:28

Indeed. (See my earlier) comprehensive QTPs for both equipment and installations will have been done.

Only one high speed sled test was carried out by MB for the GQ 5000 Tornado upgrade. There were no independent witnesses. Some time after the test QinetiQ reported in 2002 that, "The results recorded for the rear seat occupant ejection event (98-percentile) were successful, showing full parachute canopy inflation at 2.82s at a height of 36 feet above ground level". A tree level deployment seems a bit tight for me, with no consideration given for any sink rate.

The 2015 Air Commodities report does make it clear that, "ACT is not in a position to underwrite the safety of the items on aircraft; this is the responsibility of the Platform PT and RTSA. The Platform PTs and RTSA must accept any hazards associated with the continued use of these systems, with the risks endorsed by the Duty Holder." Would like to see that endorsement. Prior to the introduction of Safety Assessment Reports (SARs) in 2015 recommendations were articulated in individual AECs/SCRs, however no AEC/SCR was prepared for the GQ5000. Furthermore, there is no Certificate of Design for GQ5000 and GQ1000.

The Air Commodities report also points out that "The parachutes covered by this Safety Assessment Report are manufactured and supplied by Airborne Systems Ltd; either directly or via Martin-Baker Aircraft Ltd for seat-mounted parachutes, both being recognised internationally in the design, development and manufacture of parachute and aircraft escape systems. Airborne Systems Ltd is currently MOD Design Approved Organisation Scheme (DAOS) (ref: ALTG/07/03/11/291) approved for the equipment covered within this Safety Assessment Report, as is Martin-Baker Aircraft Company Ltd (ref: UK.MAA.DAOS.154), providing confidence that the company's' Quality, Safety and configuration management systems employed should be robust and effective."

It does appear that Airborne Systems and Martin Baker were allowed to carry out their work, unsupervised because of their 'good name' and reputation. Perhaps it is significant that on 22nd July 2014, after Tornado and Hawk accidents, the MoD drew up a tender document for the “delivery of Safety Assessment Reports (SARs) to detail the safety arguments and supporting evidence for the Aircrew Escape and Survival (AES) equipment covering: risks to wearer, hazards to relevant air platforms and fitness for purpose”. The reason for doing this was that “Aircrew Escape and Survival Safety Documentation does not satisfy current requirements, exposing Duty Holders legally and potentially Users to unknown or unquantified risks.”

DV

EAP86

20th Mar 2018, 17:17

DV

'good name' and reputation have nothing to do with it. The wording of Def Stan 05-123 used to say something like "the certifications of DAOS approved firms is accepted by MOD". MOD have the right to attend any test they want to and its usually a requirement of the contract that they are given notification in advance of such events.

The effects of sink rate, bank angle, pitch angle etc. are all worked out by calculation afterwards. There is no effective way of testing all combinations at reasonable cost.

EAP

dragartist

20th Mar 2018, 18:02

I think Walbut provides a good answer. One minor point of order. the use of the term Altitude vs height. Air Density and Temperature (the mass of air) affect the fill rate. not only the air entering the canopy but the air being pushed out of the way to do so. this is where the aeroconical wins. I still have my Hendrich course notes from St Luis University and some old spreadsheets used to calculate such stuff. Perhaps the rate of descent as the subject approaches the ground may be sufficient in all probability to make the impact survivable.

oldmansquipper

28th Mar 2018, 11:54

Soz posted an incorrect link earlier,

Someone mentioned Chalgrove housing developments earlier in this thread.

There was a council meeting last night...interesting outcome.

Rethink needed after council rejects Chalgrove Airfield plan | Oxford Mail (http://www.oxfordmail.co.uk/news/16120190.Chalgrove_home_plan_blocked_by_councillors/)

Chugalug2

28th Mar 2018, 13:23

Thanks OMS, as you say interesting, or perhaps just irritating while we go through the long drawn out saga of MBA staying in situ and any chance of development there being quietly killed off? This orchestrated charade no doubt worked well enough in the days of paper and ink, but in these digital days of everyone knowing what everybody knows it simply places the various players in uniform and complete contempt. As for MBA, cheap at half the price?

Sven Sixtoo

1st Apr 2018, 20:04

DV

In the case of a zero zero ejection, while the seat is moving upwards under the force from the rocket motor, the drogue gun fires and when the drogue chute deploys it rotates the seat around so that the crewman is moving upwards, feet first. When the scissor shackle releases from the seat and the main chute deploys, the occupant and seat are still moving upwards. In this case it is effectively the inertia or kinetic energy of the seat moving upwards that provides the energy to inflate the chute, which is partially if not fully inflated when the occupant reaches his/her apogee at around 200 -300 ft depending on weight.

Walbut

I can confirm this from experience. The most surreal part of my Martin-Baker ride (0 ft / about 65 kts) was looking up (in my frame of reference) to watch RAF Valley receding rapidly in the overhead, then looking down to see my boots pointing at the sky.

tucumseh

20th Apr 2018, 10:16

This case drags on. The Health and Safety Executive's legal department have found it necessary to forward exculpatory evidence to Martin-Baker's solicitors, proving MoD knew of the risks from Day 1 (introduction of Scissor/Drogue Shackle release mechanism). This was denied in court, and the HSE's charge was based on MoD's claim NEVER to have known the Drogue Nut should not be over-tightened.

Also, and despite reminders after the accident NOT to torque load the nut (also reflected by the CAA in Emergency Mandatory Permit Directives), the MoD chose to ignore this and still insists on it being torqued to 50 lbf in.

If MoD is permitted to ignore such directives, and destroy its corporate knowledge, at what point does providing warnings or advice to MoD become utterly futile? It was HSE's case that, had Martin-Baker provided (reiterated) a warning in February 1990, then MoD would have heeded it and Sean Cunningham's parachute would have opened. At any time, but especially given this fresh evidence, that is one hell of a jump.

caped crusader

20th Apr 2018, 13:18

Does this new evidence mean that there might be a re-trial?

tucumseh

20th Apr 2018, 14:15

Does this new evidence mean that there might be a re-trial?

It will be interesting to see if anything transpires. It certainly represents a shift in attitude from the HSE. If this latest evidence had been presented in court, who knows what the judge would have done, regardless of plea. But it does make HSE's claim to have conducted a 'thorough investigation' look risible. The significant point now is that, having dismissed previous evidence of innocence as 'irrelevant', the 'new' evidence is deemed relevant enough to warrant notifying the defence, and witnesses, that this action has been taken. I guess much depends on whether Martin-Baker want to do anything.

Wander00

20th Apr 2018, 15:39

Hopefully M-B will take the escape offered and tickets for the retrial sold through the usual agencies

Treble one

20th Apr 2018, 15:52

tucumseh

20th Apr 2018, 16:09

Treble one

if this is true

A picture speaks a thousand words. A video screams.

Chugalug2

20th Apr 2018, 19:20

TO:-
if this amounted to something beginning with P?

Any sympathy felt for MB must be reconciled with the effect that their pleading guilty had on efforts to reform the mess that is UK Military Air Safety. If they had not taken the hit but instead fought the charge then perhaps more lives might have been saved in the long run, in addition to those saved by their excellent products.

I now feel little sympathy as a result of that supine act. As to the 'P' word, as it said in the Nationwide ad, I think we'll find that it doesn't work like that.

glad rag

21st Apr 2018, 00:01

Hopefully M-B will take the escape offered and tickets for the retrial sold through the usual agencies

Not a chance.

Treble one

21st Apr 2018, 11:31

tucumseh, I was being cautious in case any legal eagles are watching.....

Chugalug....I suspect you may be right.

tucumseh

21st Apr 2018, 13:05

Treble one

Thanks. The move by HSE's legal department is, in my opinion, the first sign of any legal entity doing their job properly. Too late I suspect.

Perjury? Not relating to the video. More a case of loss of corporate memory. But an indictment of the so-called investigation, especially as the Service Inquiry admitted MoD had stopped training groundcrew correctly. But elsewhere? How fine is the line between perjury and lying by omission? 'I promise to tell the whole truth....'

Well said Chug.

AnglianAV8R

21st Apr 2018, 13:55

But elsewhere? How fine is the line between perjury and lying by omission? 'I promise to tell the whole truth....'

Well said Chug.

Nail hit fairly and squarely there.
Back in the day, newly recruited Constables were taught about their primary duty: That of detection and apprehension of offenders. They were taught that it was their duty to present ALL the evidence before the Court and enable the Court to make an informed judgement. It was impressed on the newbies that Presenting ALL the evidence was fundamental to the justice process. Evidence was defined as "anything material that tends to prove or disprove the case and it is the duty of the Police to bring ALL the evidence before the Court".
Sadly, it seems that truth (the whole truth) is sacrificed all too often and without it, there is no justice.
To deliberately withhold evidence material to the case and thus influence the outcome is a clear contempt and may also fit the definition of perjury, with potential overlap, depending on the individual case.

oldmansquipper

5th Jun 2018, 18:22

Meanwhile, back at Chalgrove airfield, it's development into 3000 houses appears to be stalling......

Lack of funds could put an end to Chalgrove Airfield plans | Oxford Mail (http://www.oxfordmail.co.uk/news/16094114.Lack_of_funds_could_put_an_end_to_Chalgrove_Airfiel d_plans/)

tucumseh

5th Jun 2018, 18:40

Very interesting OMS....
Last week the Lincolnshire Police and Crime Commissioner directed the Chief Constable to investigate possible failure to disclose evidence. The Health and Safety Executive states it has not seen this evidence; slightly embarrassing given it wrote to the judge before sentencing telling her it was 'irrelevant'. She proceeded on that basis.
HSE has also complained to a potential witness (had the case been heard in court) that he did not submit other, related evidence. Embarrassingly, the witness has produced the HSE's acknowledgement of receipt.
What a tangled web...

Chugalug2

6th Jun 2018, 07:14

OMS, your link takes us further down the road hinted at by your previous one at #618, and MBL appears likely to remain at Chalgrove. The withholding of evidence has resulted lately in the release of many from prison who were thus improperly convicted. Some can fess up to systemic failure it seems, but not so UK Military Air Safety unfortunately.

This thread is about the avoidable and tragic death of Sean Cunningham. The system that should have prevented his death instead ensured it and cries out for total reform. Instead we have the farrago outlined by tuc above.

MBL will remain at Chalgrove, the MAA will continue to deny the truth, and the VSOs responsible for the broken state of UK Military Air Safety will continue to be protected. Or at least that appears to be the de facto policy of the RAF High Command...

airpolice

6th Jun 2018, 07:17

Chug, are we not yet at a point where we can evidence that an offence has been committed, and therefore should be reported to the Police?

Chugalug2

6th Jun 2018, 07:28

airpolice, it depends which offence you mean. Certainly the illegal order given by an RAF VSO to suborn the UK Military Airworthiness Regulations was reported to the Thames Valley Police. Their Deputy Chief Constable said that it had nothing to do with them, or words to that effect. The RAF Provost Marshal didn't even bother to reply...

tucumseh

7th Jun 2018, 08:14

In the Thames Valley Police case referred to by Chug (Nimrod XV230), the DCC claimed they could not proceed as there was 'little chance of witnesses coming forward'. She was sitting on witness statements, and replying to the letter that had submitted them. Not unlike what I describe above, but this time it is the HSE's principal investigator.

Airpolice, a complaint has been made, in May 2017. That is part of what the P&CC has instructed the CC to address. From other threads you will glean there is far more to this. Formal complaints have been made in a number of cases. Most police forces have not replied. Some just pass the buck. For example, Police Scotland (and Strathclyde Police before) acknowledge offences were committed by MoD/RAF on Chinook ZD576, but say it is for the Metropolitan Police to investigate as they were committed in London. The Met simply don't reply. Too busy tax collecting.

tucumseh

26th Jun 2018, 05:21

Update.

The Health and safety Executive has claimed to both police and judge that the Mk10B parachute release mechanism (scissor/drogue shackle arrangement) is unique to the Mk10B seat in Hawk, therefore witness evidence that both aircrew and groundcrew/maintainers where taught from 1952 how it works, and how to maintain it so that the assembly can disengage, is 'irrelevant'. The fact there is a 107 minute RAF training video, and umpteen servicing schedules from various users, disproving this HSE claim was also deemed 'irrelevant'. Lincs Police Chief Constable has accepted HSE's claim without checking facts. Those on pprune who have actually seen a seat may have a view on this....

Quite why Martin-Baker continue to put up with this is anyone's guess, but oldmansquipper may very well be right. However, the company has now reacted and called forward witness evidence that the HSE claimed to the judge was irrelevant (that word again), despite never having actually spoken to the witnesses or taken evidence. That the HSE has misled the judiciary and police is now the subject of a formal complaint, so that is perhaps a good place to stop....

Someone should write a book.

Rigga

26th Jun 2018, 20:21

Not too sure about how a book might be filled out sufficiently but a short (comedic flight safety) film might be more suitable.

pulse1

26th Jun 2018, 21:03

Rigga, I suspect that tuc had tongue very much in cheek when he wrote Someone should write a book.

In the Foreword to the book* which has been written, Tony Cable says it "will fascinate and anger you in equal measure". I am afraid that there is little room for humour.
* "Breaking of the Military Covenant" by David Hill. Proceeds to Help for Heroes I'm sure that a PM to tucumseh would provide more details of how to purchase it.

airsound

26th Jun 2018, 21:28

Slight correction to that title, Pulse - it's 'Breaking the Military Covenant - Who Speaks for the Dead?'

Not sure if this is allowed, but I'll try, bearing in mind that the book is not for profit

https://cimg4.ibsrv.net/gimg/www.gmforum.com-vbulletin/300x450/coverfinal_dd6f602faf2e40d21037ab61bb66c4392894731c.jpg

Watch this space

airsound

Chugalug2

26th Jun 2018, 22:28

Many here will be familiar with the MB series of ejector seats, even those as ancient as me. We all know that the scissor drogue shackle arrangement that tuc speaks of was common to all Marks from the Mk2 until the Mk10 in the Tornado (but not in the Hawk) introduced a different arrangement. Thus the MOD (and indeed the Air Ministry before it) was fully familiar with it, and RAF training has taught aircrew and ground engineers alike from the very first. For HSE to claim that the Mk10B drogue shackle arrangement in the Hawk was unique is bizarre. To further claim that evidence to the contrary in the form of a 1950's training video (from the original film) showing that very same arrangement and the sequence to be followed by servicing personnel is 'irrelevant' goes beyond bizarre and enters the dark world of MOD style tactics.

Sean Cunningham deserves better than this, we deserve better than this. The British Establishment seems to place its trust in sticking close to nurse for fear of finding something worse. It needs to know that nurse in this case is a killer and would do best to disown her and bring her to book before she kills yet more.

The book tuc mentions has indeed already been written, as disclosed by pulse1 and airsound. It is required reading for all who care about air safety, particularly UK Military Air Safety, which is in dire need of reform. At the moment it is a dysfunctional and broken system.

Chugalug2

25th Jun 2021, 21:54

Well, here we are three years later (-1Hr) and in addition to the excellent book mentioned above by airsound is this one, again by David Hill :-

RED 5: An investigation into the death of Flight Lieutenant Sean Cunningham: Amazon.co.uk: Hill, David: 9781706149231: Books

now in its 4th revision (June 2021) and available in Kindle form for a mere £2.99, as well as a paperback edition, another bargain at £6.99. As ever, all proceeds go to charity. David Hill adds this important revision to his other three books; Their Greatest Disgrace, Breaking The Military Covenant, and The Inconvenient Truth. No-one now can offer the excuse we were never told about that. We have been now, and as aviators it concerns us all....

https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/333x499/41ecntje1ps_sx331_bo1_204_203_200__e9531742212b8a5b991ee3980 a2201b2077d4230.jpg

DODGYOLDFART

28th Jun 2021, 21:38

Red 5 - Got it today and must admit I am seriously impressed with the book and David Hill the author. Well researched and despite the various and somewhat complex technical issues involved it is presented in such a way that makes the facts jump off the page. Extremely well done David.

DOF

oldmansquipper

29th Jun 2021, 18:51

An excellent book. Several ‘agencies’ should hang their heads in shame….(IMHO)

Is David still considered Mr Vexatious and on the Whitehall naughty step? Perhaps Tecumseh would know.

Jackonicko

29th Jun 2021, 20:18

Am I alone in being a little uneasy about this prosecution? Very difficult to put into words.

Here we have a magnificent world leading British company of undoubted excellence to go through the wringer. As I read the BBC, this is not manslaughter or criminal negligence. We are not talking about a dodgy operation running fun-fair rides, or operating unsafe ferries.

I suppose the most favourable outcome now would be for the fine detail of the problem/ cause to be understood and acted on [although we would hope that was done days after the tragedy], and that any fine was transferred without delay to the victim's family. Any senior employee seen to be negligent should be dealt with appropriately.

Please don't shoot the messenger, I have never sat in a bang seat, but I do grow weary of this liitigious society where every accident has a blame to be attached.

I have sat in bang seats, and share your unease, LB.

tucumseh

30th Jun 2021, 05:59

Like most posts on this thread, LB's was made before it was known that MoD concealed the existence of at least twelve RAF training films, imparting the information Martin-Baker were accused of not providing. Nor was it widely appreciated that the Judge, Mrs Justice Carr, actually named in court one MoD recipient. But she had to accept Martin-Baker's guilty plea. (The book explains the process whereby he signed for the information, and it was disseminated within MoD).

The company did not commit manslaughter or criminal negligence. But a prima facie case exists that MoD personnel did, by issuing instructions to technicians NOT to follow Martin-Baker's information, or the technical training provided by the RAF.

The fine detail of the problem was understood, and was dealt with twice in the training films. Also, in the technical publications and training provided by Martin-Baker (until MoD cancelled the contract in 1983). After the accident, MoD even issued a directive that Martin-Baker's information was STILL NOT to be implemented.

In 2018 Jonathan Bayliss was killed at RAF Valley. TWELVE factors in the Cunningham case were repeated. MoD had assured the Coroner in 2014 that they were being, or had been, acted upon. It lied. A recurring theme. And not forgetting that the Cunningham accident was itself a recurrence, repeating the failure that killed Simon Burgess - failure to conduct disturbed systems testing.

And yes OMS, you're regarded as vexatious if you ask questions about this! By both MoD and the legal establishment.

dctyke

30th Jun 2021, 09:07

Sadly ironic that when we had unit seat bays anyone attempting similar sort of work on a installed seat would have most probably faced a tech charge. It most definitely would not be sanctioned. We had a harrier gr7 sat on the ground in the USA for nearly a week so a seat team could come out to change an item that was a much simpler task.

Would like to see the risk register for the removal of seat servicing and support at unit level.

RetiredBA/BY

30th Jun 2021, 09:11

Got my copy yesterday, superb book, but what an incredible revelation of incompetence and downright dishonesty in both MOD and certain aspects of RAF training or lack of. On page 135 it reveals that only 2 aircrew of 40 questioned knew how to check the top latch was correctly engaged, unbelievable.. That , in my day certainly and should be now, , was one of the simplest but most vital checks on the seat, done carefully each time EVERY time.

Frightening, that training had fallen to this level.

My take is that the prosecution and conviction of MB was a miscarriage of justice.

Mandatory reading for anyone at all interested in this accident or ejection seats in general.

Bob Viking

30th Jun 2021, 10:00

longer ron

30th Jun 2021, 10:12

Just to clarify though - that it was not the top latch in the XX177 accident.
On XX177 the scissors shackle had been overtightened which prevented the chute deploying.
The seat pan firing handle was suspected as not being pinned/checked/seated correctly which is what caused the seat to fire due to the SPFH being inadvertantly pulled out of its housing during after start checks.

Red Line Entry

30th Jun 2021, 11:28

Bob,

Please - this is genuinely not an attempt to trip you up or embarrass you, but: would you mind, without looking it up, just articulating what you actually check for with the TLP?

tucumseh

30th Jun 2021, 12:08

For those commenting before reading the book, the chapter in question is entitled 'A pattern of behaviour', and discusses the common factors between the Sean Cunningham, Mike Harland and Simon Burgess accidents.

The Top Latch Plunger issue relates to the Harland case, and the relevant extract is:

"The Top Latch Plunger, holding the seat in position until fired, had been incorrectly engaged. The assembly consists of a plunger element and a spring-loaded spigot running through its centre. (Figure 9). At the Inquest, on 19 October 2010, the pilot confirmed aircrew were expected to check this locking mechanism during pre-flight checks. But, he understood it was only necessary to ensure the spigot was correctly aligned. That, he and 40 other civilian and military Tornado aircrew he had canvassed did not know to also check the end of the plunger was flush with its housing. Only two people he asked knew this. But two is enough to indicate the correct instructions were provided by Martin-Baker. (In the same way groundcrew from Lossiemouth and Coningsby knew how to fit the Drogue Shackle nut correctly)".

So, if questioning the statement, might I suggest you speak to the pilot who gave evidence under oath.

The similarity with the Cunningham case is that MoD claimed a lack of information. The 'Figure 9' referred to reproduces a sectioned diagram of the assembly, provided by Martin Baker to MoD. It shows the "correct (plunger fully home)" plunger position, and an "incorrect (plunger not fully home)" position. BV, you may even have used it when training aircrew.

As with the Cunningham case, the book merely reproduces the information MoD says it does not have - sourced directly from MoD documents.

This repeats Chinook ZD576, Nimrod XV230, Hercules XV179, Sea Kings ASaC Mk7, and so on and on.

I say again. MoD lied.

RetiredBA/BY

30th Jun 2021, 12:25

Would it be possible for you to give us a bit more detail on the claim that so few aircrew knew how to correctly check the top latch?

That’s a hell of a claim and suggests that either I was the only one who used to teach it properly (which I know for a fact is not the case), that I myself was not teaching it properly (which I very much doubt is the case), that nobody pays any attention to ejection seat briefs (which I very much doubt) or that the author or reader is making incorrect assumptions.

I’m not suggesting that either you or the author are being slanderous in any way. I know you have a particular vested interest in ejection seat safety but I can assure you that in my 22 years of RAF service thus far, everyone I have ever met takes it as seriously as you do. So that claim seems a little off target to me.

The top latch in particular (I assume we are talking about the plunger) is one of the most vital checks and has always been stressed to pilots as such.

BV

BV If you properly read what I wrote you would not need to ask the question.

As I said, has been repeated here by Tecumseh , I was quoting what was written on p 135 of the book and I was quite astounded at that statement as I thought EVERY pilot who used ejection seats would correctly check the latch.

I suggest you read it.

Please note the comments on p33 re making the seat safe, pins being replaced AFTER the jet has come to a halt on chocks, engine shutdown, NOT as part of the after landing checks whilst the aircraft is moving.

The book states, not me, that the unsafe seat was not identified by no fewer than 7 individuals on 19 checks !

I seem to remember you were critical of me. advocating this procedure, as was done in my time on 2,3 and 4 seats, in an earlier post.

tucumseh

30th Jun 2021, 15:23

Further to RetiredBA/BY's post, the other statements he correctly mentions (pins, unsafe seat not identified) were taken from MoD reports.

Bob, I do not doubt that the pilots you taught were attentive and took ejection seat safety seriously. But some very senior officers (and Civilians) demonstrably did not. See dctyke's post, above. If the regulations and instructions had been followed, this accident would not have happened. Who withdrew the wherewithal to satisfy those regulations and instructions? Again, dctyke nails it. What does the risk register (or hazard log, or impact assessment, or Safety Case) say about the decision to withdraw that capability? A rhetorical question - there was no Safety Case. Again, as admitted by MoD. Been there before.

Bob Viking

30th Jun 2021, 19:54

RLE.

It would appear to be cheating now but I could tell you even when drunk that it is ‘spigot in line with the plunger, plunger in line with (or slightly recessed) the housing’. I also fully understand why that is important and I knew it before Mike Harland’s accident.

I would be genuinely shocked if 38/40 of my FJ colleagues honestly did not know that when questioned.

BA/BY

With regards to the pin in whilst taxying thing (I haven’t read the book and I’m not likely to, so quoting page numbers won’t help) I’ve never had a problem with it. Clearly some people have and the latest modification to the ejection seat firing handle housing has taken care of that.

Remember that lots of things went wrong for Sean and I’m not going to get drawn into any public conversations about the incident.

Please don’t think for one second that ejection seat safety is not taken very seriously nowadays. I can assure you it always has been on every unit that I have served on in three different Air Forces.

BV

dctyke

30th Jun 2021, 20:17

When I was a sqn wpns tm I went through mandatory cockpit ejection seat safety certification check individually with all the aircrew once a year. One of the most emphasised of those checks was the top latch plunger.

Bob Viking

30th Jun 2021, 20:24

That is still done which is why I am a little sceptical about such a claim.

BV

tucumseh

1st Jul 2021, 06:06

Bob Viking / dctyke

What you're actually highlighting and confirming is that, despite correct information and training being provided, initially by Martin-Baker and then MoD/RAF, poor practices were allowed to develop, and were perpetuated by savings at the expense of safety. (The Nimrod Review in a nutshell). Thank you for that support.

I cannot speak for Bob's case, except to reiterate what was claimed at the Inquest. But the excellent training dctyke was obviously given became impossible to implement due to these cuts. In this case, the demise of seat bays combined with Engineering Authorities issuing illegal Routine Technical Instructions. Who met their legal and moral obligations by reporting these violations? To whom, and what was their reaction?

For example, few, if any, at Scampton or Valley would understand that an RTI was strictly prohibited in this case. But they would all know, intuitively, that something was very wrong. Any trained fitter, of any trade, would know not to torque the drogue shackle nut. (Quite apart from the fact Martin-Baker's instructions said DO NOT TORQUE). So why the hell instruct maintainers to do it? And why (apparently) did no-one go back to the Issuing Authority and say THIS IS BOLLOCKS, DID YOU MISS YOUR FIRST DAY'S TRAINING? As the book says, this is akin to a prospective pilot's first lecture on lift.

The Service Inquiry made the ludicrous claim that no basic engineering principle had been breached. Here's one... The effect of friction. That one claim should, in my opinion, prompt the Chief Engineer to launch a review of engineering training, and for the Convening Authority to reconvene the SI, under a trained engineer. Not to mention it is even more exculpatory evidence in the persecution of Martin-Baker.

Despite your reluctance to read the book it Bob, it is the only place you'll find details of how to avoid recurrence, which is something that anyone in the Services and MoD should, I believe, be keen to learn. However, I know the MAA and legal establishment disagree. But I also know from your posts I'm not a lone voice, another claim MoD has made!

Chugalug2

1st Jul 2021, 07:21

BV :-
I haven’t read the book and I’m not likely to, so quoting page numbers won’t help

Bob, I find your rather dismissive attitude to David Hill's book Red 5 surprising and very much out of character. Presumably it isn't the cost of buying either the Kindle or Paperback editions as both are at a minimal price, and whatever proceeds there are go to charity. I would not have expected a closing of mind from someone who has always been a voice of moderation and authority on this forum. David Hill writes from the knowledge of how the system is supposed to work, how it used to work, but how it stopped working and why. He has been at pain to emphasise that it was deliberately subverted from the very top and, despite the professionalism of those like yourself who strive to maintain standards behind the Station Gates, once dealt the savage cuts in finance and experienced manpower the inevitable spread of unairworthiness throughout the fleets led to the numerous airworthiness related fatal accidents featured in this forum, including of course Sean Cunningham's.

This revised edition is simply the latest offering from him, but all his books are authoritative and based on evidence. He is not about attacking the RAF, or rather what I would call the "real" RAF, ie that which operates from behind those same Station Gates, but against those VSOs that perpetrated this crisis in Air Safety and those who have attempted to cover it up ever since. It cost us the Air Cadet gliders, now reduced to a shadow of their former selves, and our Maritime Patrol capability, again only now being rebuilt at long last. It has cost us losses in life, material, and Air Power. Those like you who serve in the RAF are naturally reluctant to accept that, but all the more reason to read what David Hill says with an open mind. Then decry him if you must, but in all fairness read this book first!

dervish

1st Jul 2021, 07:57

Some excellent posts here. I share chug's view and that of others. This book is required reading.
I hope the author doesn't mind, but this passage from page 70 stands out....

"Why was MoD signing a report arising from a British Aerospace query? Because Martin-Baker had correctly notified MoD. This is precisely the kind of empirical evidence required by investigators, and again indicative of the lack of depth of all investigations. Martin-Baker were accused of not advising MoD of the issues addressed by this investigation. MoD signed the report. Q.E.D."

That leaves me utterly speechless at the prosecution's gall and Martin-Baker's guilty plea, and despite producing the evidence proving them innocent of the charge, the author doesn't hold back from criticizing them. Their plea, to avoid upsetting MoD (the author directly quotes their lawyers), defeats justice and encourages recurrence. But the really interesting part is towards the end, The HSE investigator should be in the dock. I can't understand why the judge was happy being lied to.

This is a work of major importance. BZ Mr Hill.

Martin

RetiredBA/BY

1st Jul 2021, 08:55

[QUOTE=Bob Viking;11071126]RLE.

BA/BY

With regards to the pin in whilst taxying thing (I haven’t read the book and I’m not likely to, so quoting page numbers won’t help) I’ve never had a problem with it. Clearly some people have and the latest modification to the ejection seat firing handle housing has taken care of that.

Absolutely incredible that someone like yourself is not reading every word of this excellent book. You might just, might, learn something to your advantage, particularly as you are flying the same type, seat.

So you have no problem inserting pins whilst taxi-ing. Yet. BA never had a gear pin problem till their 787 incident at LHR two weeks ago, very expensive but very fortunately without injury. Their procedures WILL no doubt change after the AAIB conclude their investigations.

I am still at a total loss as to why you guys are installing pins whilst taxiing when such a procedure was an absolute no no, for obvious reasons in the interest of safety as described on p33 of the book, in the MUCH bigger RAF during my time. We were not amateurs and I would argue to any court etc. anywhere, that if our procedures had been practiced there is very good chance that this accident would not have occurred

Apart from essential actions for after landing the only place for eyes is outside the cockpit, particularly if taxiing in a formation. Leave the seat pins til shutdown, when you can give it your full and complete attention and a careful visual check, each time every time.

Buying the book may just be one of your best purchases !

( and just to be clear, I was a. RAF standards QFI and an ejectee, so have a close interest in and some knowledge and experience of these matters)

Bob Viking

1st Jul 2021, 10:51

tucumseh

1st Jul 2021, 14:08

The Hawk I currently fly has a much updated seat that does not use the mechanical scissor shackle. The seat pan handle modification also makes it impossible to install the pin in the wrong place.

BV

I assume you realise that the existence of the gas shackle is one of the many pieces of evidence that demonstrated MoD and the Health and Safety Executive lied to the court? The HSE claimed Martin-Baker had no understanding of the risk, yet they had designed it out with the gas shackle. We're still waiting to hear from MoD precisely how the risk could remain tolerable and ALARP after 1983, when the decision was made not to fit the gas shackle in Hawk, but put it in (e.g.) Tornado.

Also, we await news of why MoD refused so many times to embody the firing handle shroud.

It is indeed gratifying to see a current pilot so willing to counter MoD and HSE's evidence to the Judge that these two issues were irrelevant, as they were completely divorced from the risks of incorrect strap routing and an over-tight shackle nut and bolt. You would have made an excellent Defence witness, as I suspect you would also have been able to counter the HSE's claim to the Judge that the Mk10 seat was the ONLY one to ever have a scissor shackle. MoD did not demur. But I suspect your career would have suffered!

RetiredBA/BY

2nd Jul 2021, 10:16

I know and respect your experience and I’m not trying to pick a fight.

If we’re going to play the willy waving game though I am a CURRENT Hawk QFI with very nearly 3000 hours on Hawks (T1/T2/115/165/166) and have at various times been a standards QFI as well in three different Air Forces so I am hardly an amateur. I do not have direct experience of ejecting though so you definitely trump me there.

Please remember that the report is discussing the Hawk T1 and its ejection seat. The Hawk I currently fly has a much updated seat that does not use the mechanical scissor shackle. The seat pan handle modification also makes it impossible to install the pin in the wrong place.

I know you feel very strongly about installing a pin whilst taxying because of the procedures that were in place when you were flying on bang seats. However, vacating the runway and stopping (that is the current recommended procedure) to install the pin is not inherently unsafe. In fact I would argue that the sooner you can make the seat safe, the better.

I know we can dream up scenarios where a ground ejection during taxy back to dispersal is necessary but personally I would rather take my chances with vacating the aircraft manually once I am at safe taxy speed.

I know we will never agree on this but the current procedures were not dreamed up on a whim and have been subject to extraordinary levels of scrutiny by people with a lot of experience and approved by individuals who would be required to represent themselves in court.

BVNo willy waving on my part. The point I was making is that I am not an “ armchair quarter back”. You may know, others may not.

If the current SOP is to clear the runway, STOP, and then replace the pins I see no issue there at all, seems perfectly safe and reasonable.

However, if the likely procedure ( inserting pin by feel at 50 Knots on a formation roll out) as suggested in 1.4.2.22 in the service enquiry WAS done, that is totally different and I can think of NO reason for such premature action.I have my views on that based on what was practiced, totally different, during my 12 years of ejection seat occupancy and during which I was the refresher course instructor of several very influential and senior pilots including commandant ( des) of CFS.

None did anything remotely like that.

I rest my case.

pulse1

2nd Jul 2021, 11:22

I know we will never agree on this but the current procedures were not dreamed up on a whim and have been subject to extraordinary levels of scrutiny by people with a lot of experience and approved by individuals who would be required to represent themselves in court.

I am nearly through this excellent book and one of the main points of it seems to be that, above a certain rank, the responsible individuals do not have to represent themselves in court. Their involvement is frequently covered up by omissions and lies. The farce of a trial of Martin Baker is a classic example.

The book also exposes the truth that many safety issues are not "subject to extraordinary levels of scrutiny by people with s lot of experience. It appears that we cannot afford them any more.

biscuit74

2nd Jul 2021, 12:29

I am nearly through this excellent book and one of the main points of it seems to be that, above a certain rank, the responsible individuals do not have to represent themselves in court. Their involvement is frequently covered up by omissions and lies. The farce of a trial of Martin Baker is a classic example.

The book also exposes the truth that many safety issues are not "subject to extraordinary levels of scrutiny by people with s lot of experience. It appears that we cannot afford them any more.

The idea that the VSOs responsible do not willingly come to court to explain their policies and actions seems extraordinary. Surely if they are truly leaders they should be be proud of what they do and what they stand for, happy to defend their behaviours. To do otherwise lets the whole organisation down, doesn't it? Certainly not much of a match with the blurbs on their website.

'Cannot afford them' (experience safety people.) Really? That is back to the old saying " If you think safety is expensive, try having an accident."

Double Hush

2nd Jul 2021, 12:32

tucemseh,

"Also, we await news of why MoD refused so many times to embody the firing handle shroud."

Back in the day, as an 'end user' I was involved with some trials for potential MODs to the seat after the Sean Cunningham accident. The revised SPFH 'faceplate' was a no-brainer. The shroud was more nuanced. On the Hawk T2, the SPFH is angled forward quite markedy and the proposed shroud denied visual confirmation of the SPFH safety pin status. The only way to check the pin and therefore seat status with the shroud fitted, either sat in the seat or looking in from outside, was to leverage the handle back, quite forcibly. Not a good move if the seat wasn't safe. That problem prevented the immediate fitting of the shroud to the seat in the T2. Whether that is still the case, I cannot say.

BTW, I have ordered the book. I just need Covid restrictions to be relaxed so I can return to Blighty and collect!

tucumseh

2nd Jul 2021, 13:19

Double Hush

Many thanks. Apologies if I didn't make it clear, but the 'many times' I mentioned were in the 1980s, at the same time the gas shackle mod was rejected. After the accident, MoD and the HSE claimed that MoD initiated the mod/design as result of Sean 's death. Nothing could be further from the truth.

In 2016, the HSE then argued in court that if it could be shown a modification to the handle could have prevented ejection, then Martin-Baker were guilty of negligence for not having taken such action. This overlooked that Martin-Baker HAD taken action. This wasn't the first or last time the HSE claimed the company could set about modifying aircraft without a by your leave. At no time did MoD demur, so these outright lies became accepted fact, and were later repeated by the BBC in an episode of 'Defenders UK', in which the HSE lied again. The HSE and BBC (and Judge) were in possession of the facts before any of these claims were made. They weren't errors, they were blatant lies.

tucumseh

2nd Jul 2021, 13:32

The idea that the VSOs responsible do not willingly come to court to explain their policies and actions seems extraordinary. Surely if they are truly leaders they should be be proud of what they do and what they stand for, happy to defend their behaviours. To do otherwise lets the whole organisation down, doesn't it? Certainly not much of a match with the blurbs on their website.

Those familiar with the Mull of Kintyre case will recall that MoD successfully argued a legal point that if the authors of 'evidence' or claims were not in court, then their work could not be discussed. MoD then prohibited the very senior officers involved (Wratten, Day, Graydon, etc.) from appearing at the Fatal Accident Inquiry. Some years later, Wratten claimed to Jeremy Paxman on Newsnight that Sheriff Sir Stephen Young 'rejected the option of calling my colleagues and I to give evidence. One has to ask why (he) pursued such a course of action'.

POBJOY

2nd Jul 2021, 16:31

Having been a user of shackles since my ATC gliding days (and subsequent marine use) I awaited the 'book' with keen interest to see how this simple 'connecter' fitted in with a high tech escape system.
The answer was simple there was a requirement to connect a rope type end to a metal fitting.(in gliding usually to a weak link assembly) (in marine use a rope to a chain). In both cases the 'pin' is load bearing and the nut stops the pin working loose and falling out. Frequently the pins have 'eyes' which can be wire locked rather than a nut. In both cases shackle deformity can occur when overtightened (mainly due to thread wear). In a case where a shackle gets used on to a more technical fitting and a constant gap must be retained it is common practice to use a internal pin sleeve or spacer that prevents inadvertent gap closure. Was / is there a reason this is not common practice on the seat application or was the requirement for a new pin and nut deemed a reasonable alternative. On the basis of cost and the low number of times this was required it seems incredible that anything else was even considered for such an important component.

tucumseh

2nd Jul 2021, 17:58

Pobjoy

Your question was asked and debated here when the SI report became available. As Martin-Baker chose not to defend themselves (in order to protect MoD) there was no opportunity to ask. I’m sure it would have come up in court during what was to have been a six-week trial.

So, all that can be said (unless someone involved decades ago wants to come forward) is that the shackle bolt and nut arrangement was deemed to be the engineering design solution, and this was accepted by MoD. The type of bolt changed in the Mk9 seat, but the fitting instruction to MoD remained the same. ‘Tighten the nut until contact is made with the Drogue Shackle. Do not torque’.

This is the information Martin-Baker were fined £1.1M for not providing. MoD’s APs and Martin-Baker manuals from the 50s - 90s containing it were provided to the court and HSE. So too the RAF training films clearly showing the final test that was omitted. So too witness evidence from the head of Tech Pubs in MoD. The HSE simply told the Judge the films were ‘irrelevant’, and flatly denied the existence of the APs and manuals that were provided to both it and the Judge.

Following these instructions would prevent over-tightening and deformity of the shackle. Instead, the nut was over-tightened to such a degree the bolt was bent and new thread cut.

The question then is why, after the accident, did MoD re-issue its instruction to torque the nut to 50 lbf-in; yet again completely ignoring the instructions from Martin-Baker.

Of course, the main question is why in situ servicing was being carried out when the manuals and APs unambiguously said ‘Remove seat from aircraft’. This meant a false declaration was made that the seat was serviceable, because its serviceability could not be verified. Someone gambled when issuing the order not to follow Martin-Baker’s instructions. He lost, and Sean Cunningham died. As dctyke said earlier, we'd all love to see the risk assessment and justification.

Bob Viking

2nd Jul 2021, 19:17

I have obviously been too dismissive of the book in question. That was not actually my intention.

I just meant I’m not in a position to read it right now. I’m sure it is a good read and a valuable tome.

I should also point out I haven’t flown the Hawk T1 for over ten years so I am not so concerned by T1 procedures.

The Hawk T2, with the SPFH shroud and the pins caption along with the gas system, addresses most of the issues being discussed here.

It is also worth remembering I am an operator not a policy man and in-depth discussions of airworthiness are not my area of expertise. I can assure you though that if I was concerned about the safety of my aircraft I would not strap into it. Thus far that has not been a problem.

BV

POBJOY

2nd Jul 2021, 19:46

Chugalug2

2nd Jul 2021, 20:56

BV :-
It is also worth remembering I am an operator not a policy man and in-depth discussions of airworthiness are not my area of expertise. I can assure you though that if I was concerned about the safety of my aircraft I would not strap into it. Thus far that has not been a problem.

And there in a nutshell is the problem. Let me add immediately that I shared that same attitude back when. The difference is that I was fortunate to have served when airworthiness was run by the experts that have since been replaced by placemen, and under an RAF leadership that respected those experts and took their advice. I would further add that it was only after I retired that I learned about airworthiness and how the lack of it in UK Military Aviation has caused very many deaths and goes on doing so. I learned about it here, in this very forum. I learned about it from tucumseh and other experienced engineers who have testified here about the monstrous attack on UK Military Air Safety by RAF VSOs and of the cover up of their actions since by other RAF VSOs. So you are not alone by any means Bob.

However, the difference is that my good fortune meant that airworthiness related accidents were few and when they happened immediate remedial action was taken. The best example I can think of was the grounding of the Hastings fleet (some 80 aircraft around the world) following the crash of Hastings TG577 after take off from Abingdon that killed all 41 on board. The failure was discovered by the BoI, and subsequent checks made immediately resulted in the fleet grounded wherever they were. Because proper records had been kept airworthiness was regained slowly as rectification teams completed a complex repair including of course the two bolts that had failed (yes bolts again!). Still the penny didn't drop and I thought of it in terms of serviceability with no inkling of the difference with airworthiness. Civil aviation is no different, I spent more years with the airlines than with the RAF and still blissfully ignorant. If anyone thought about it at all, airworthiness was for the boffins and 'policy makers' as you call them. Fine if they are up to the job and not undermining it to make savings at the cost of safety!

I would respectfully suggest that you start worrying now about the safety of the aircraft you strap into and read Red5 ASAP!

tucumseh

3rd Jul 2021, 05:44

TUC Thanks for that, I assume that 'normal' or good practice would require a new nut and bolt fitted as directed and then checked for free movement. hardly a difficult operation and seemingly in the general scheme of things not expensive for what it does. I can see that in place seat servicing would be a real loss of good practice, and also a loss of a good opportunity for a loose article check at the same time. Considering the location of the only operating handle being low down in a restrictive place that itself makes a cogent inspection difficult in situ. With that mind set running the show it beggars belief that no one saw a big red light and flagged up what was quite obviously a dangerous practice for such a complex piece of safety equipment. No wonder they b..... up the glider fleet.

There's a few separate issues there.

Yes, a new nut and bolt is required every time the Drogue Shackle assembly is dismantled. MoD's report did not address this, and the Routine Technical Instruction being followed at the time does not mention it. The proper assembly instructions (not the illegal RTI) say it is to be assembled in the parachute bay as part of the duplex drogue assembly, which is later fitted to the seat in the seat bay. At that point any jamming or resistance would be obvious, as two checks are required to ensure the shackles can freely disengage. AND THEN ARE NOT TO BE DISTURBED. If they are, then you start again. Yep, it's hassle, but its an escape system that is only required to work once. If you get it wrong, someone dies. But it appears someone spotted an opportunity to save money by eliminating that hassle, without thinking through the impact. I cannot speak for Martin-Baker, but I understand they expressed grave concern at this not-so-cunning plan. So too did MoD armourers. But there's a certain type of person in MoD who sees this as the company being bolshie and awkward, that MoD knows best. Nope, they're satisfying legal obligations.

A free movement check is carried out by pilots, but it gives false confidence. The shackle lugs can be pinched by over-tightening which (as illustrated by the SI in an image of the XX177 shackle), but when this happens the lug faces are no longer parallel. This can allow free movement at the bolt, but not at the ends of the lugs. The effect is variable, and in this case the SI calculated a speed of 50kts would be required to overcome this resistance. It follows that it is likely the problem had occurred before, but only manifested itself when the seat was required at the extreme of its design envelope. (Zero-Zero). Hence, the instruction that the nut just touches the shackle when attached. That eliminates any problems caused by slight tolerance differences in bolt lengths and lug gap.

The handle issue was addressed very well by the SI, who confirmed that the seat height mechanism was required to be motored to the top after use, to allow easier visibility of the handle/pin. However, it reported that the Red Arrows maintainers had been instructed to leave it as is; the implication being this was to shave seconds off a start-up regime, which the Panel said was shorter than normal for other Hawks. I know nothing about Hawk operations, so cannot comment.

My last comment actually highlights one of the main errors made by the HSE and Judge (and MoD in general). I've never been in or worked on a Hawk. But that doesn't stop me understanding basic fitting practices taught when a sprog. Or prevent me from reading and understanding the manuals and APs (which are both excellent). The Judge rejected expert evidence from a highly qualified mechanical engineer on the basis he was not an aviation engineer. As you rightly said Pobjoy, the basics apply to other domains, such as marine engineering. Similarly, the HSE denied that the scissor shackle assembly was in any other seat, because these other seats pre-dated Hawk. A 2 year old can destroy that logic, but.... Similarly, it said information relating to previous Marks of seat was irrelevant, because they were not Mk10s. The fact that the many parts of the design remained the same was also irrelevant - although in this case the HSE went further and denied the scissor shackle was in any other seat. The Judge confirmed it WAS, since 1952, but the HSE just ignored her and continued with its claims even after the trial. What am I saying? The HSE was incompetent, and actively misled the courts and family. MoD was complicit, as it knew this and said nothing.

Chugalug2

3rd Sep 2021, 11:59

A fully revised Kindle version of Red 5 is now out containing new evidence dutifully ignored by those responsible for Military Air Safety. I can do no better than quote the blurb on the Amazon site :-

Revised and updated, September 2021. Includes and discusses new images and information from the investigation, which MoD and HSE withheld from the courts and family.
This is a story of unrelenting misconduct and injustice. Martin-Baker, designers of the world’s best escape system, were prosecuted for not providing information they had already supplied many times, but the Ministry of Defence instructed its engineers not to use. Bizarrely, the Judge named an MoD recipient in court. Applying this information would have saved Sean Cunningham’s life.
The Health and Safety Executive and Lincolnshire Police did not evaluate verbal, written and video evidence proving the allegation false. The Judge and Coroner were misled. This subversion of the judicial system has placed military aircrew, passengers and the public at greater risk.
Also discussed is post-trial misconduct by the HSE and BBC; linkages to the Shoreham Air Display accident, in which the Air Accidents Investigation Branch confirmed MoD had the information necessary to avoid the death of Sean Cunningham; and an analysis of the Service Inquiry report into the death of Corporal Jonathan Bayliss, passenger in a Red Arrows Hawk which crashed in March 2018; revealing twelve common factors with the death of Sean Cunningham.
All proceeds to charity.

RED 5: An investigation into the death of Flight Lieutenant Sean Cunningham eBook : Hill, David: Amazon.co.uk: Books

Note, if you don't own a Kindle reader, you can still read Kindle books on your PC (other OS provided for also) by downloading the free Amazon App :-

Amazon.co.uk : kindle app for pc

Haraka

7th Sep 2021, 17:50

Just now read the update on this on my Kindle.
I submit that it is worth reading as a part of this author's ongoing campaign over several years.
I would savour any qualified opinion on these cases cited..

NutLoose

7th Sep 2021, 20:23

So can Martin Baker not now appeal as a miscarriage of justice has been carried out due to evidence being withheld from the court.

Have they now not got sufficient evidence to counter sue the MOD and have their fine returned and claim for damages to their reputation?

Personally I would like to see senior officers involved in both the cover up and withholding information from the courts in the dock, because until they become personally culpable, nothing will change.

stevef

7th Sep 2021, 20:44

Lordflasheart

7th Sep 2021, 21:55

...
My understanding is that Martin Baker already had all the evidence we are discussing and still chose inexplicably, at the last minute, to plead guilty. As a result there was no trial as such.

Charges read, guilty plea entered, possible statements in mitigation, punishment administered, end of.
Appeal against their own fully informed guilty plea ? .... Self-inflicted injury, m'lady.

Note also that the intended judge was replaced late on in the proceedings.

Pleading guilty prevents a full trial, at which there was a good chance all the real evidence might have been revealed. Who knows where that might have lead, given that a couple of years earlier some authority stated that there would be no prosecution (of anyone)

LFH
...

NutLoose

7th Sep 2021, 22:17

There may be technical reasons that I'm unaware of but, as a licenced aircraft engineer, I find it hard to understand why servicing instructions (or common sense) would stipulate pinching a shackle connection. It defies normal engineering practices. On publicised evidence it seems to me also that Martin Baker has been penalised for a servicing error that they're not responsible for.
I'm open to rebuke.

As another LAE I totally agree with you. And that’s where the military fall down hands over feet, as a licensed engineer your word is more or less final, you cannot and should not be coerced into signing for or carrying out anything you deem dangerous or unsafe and you would consult with the manufacturer and follow their recommendations as you would carry the can.

tucumseh

8th Sep 2021, 06:14

Nutloose

Regarding an appeal, Martin-Baker pleaded guilty, and their reason is given in the book. (And also the reason given by their solicitors, which is slightly different). Lincs Police and the HSE have both refused to assess the verbal, written and video evidence that M-B were innocent of the charge.

As the book says, perhaps the most bizarre aspect of the case is that M-B were accused of not providing information to MoD, and the Judge named an MoD recipient in court. The book explains the process, and why the named person was the correct person to have been informed. The Judge gave SIX other reasons in her remarks why M-B were not guilty, but had to accept the plea. She admitted this caused her 'great difficulty'.

To reiterate, all proceeds go to charity.

falcon900

8th Sep 2021, 09:20

As has been said already, but perhaps Occams razor requires to be said again : MB took one for the team.
All loose ends tied up, a guilty party blamed and punished. All legal lines of enquiry closed. Nothing more to see here.
The fine is a small price to pay to further cement the cosy relationship with a key customer, and it was only the company which plead guilty, not any individuals.
As cynical an act as I have seen for some time, but not unprecedentedly cynical.

tucumseh

8th Sep 2021, 14:37

Falcon900

Indeed.

The trouble with such a cynical commercial decision is that it ignores the legal obligation to endeavour to prevent recurrence. However, MoD has the same obligation, and ignores it with impunity. So, too, the Coroner, but he was lied to in 2014; the scale of which only became apparent when the SI report was released after the Inquest. An even more cynical decision by MoD, preventing independent assessment. When the details were provided to Coroner Stuart Fisher before M-B's trial in 2018, he immediately sent them to the Judge. She was also lied to, but unlike the Coroner had all the necessary exculpatory evidence.

All these machinations make for a complex story; but at the most basic level the charge against M-B was irrelevant to the accident. The HSE's position was that, had the information been provided, the death would have been avoided. Nonsense. The information WAS provided. Not only did MoD choose not to implement it, it issued contradictory instructions; and did so again after the accident. That decision by MoD divorced supply of information from the accident.

And then Jonathan Bayliss was killed, the SI report repeating 12 recommendations.

In 2009 Haddon-Cave's report concentrated on a poor safety case. Here, there wasn't one. I wonder how he'd have dealt with this had he continued as Judge? Did he recuse himself, recognising the evidence would contradict much of his report? How convenient it wasn't aired in court.

Chugalug2

8th Sep 2021, 21:50

NutLoose

8th Sep 2021, 22:14

Can the family not bring a private prosecution / case against the VSO involved and see him answer for it?

Lordflasheart

9th Sep 2021, 07:47

...
And then Jonathan Bayliss was killed, the SI report repeating 12 recommendations.

Well, let's hope the Bayliss Coroner reads the XX 204 SI thoroughly and understands all the implications and repetitions therein. I could recommend swotting up on PPRuNe and reading a few good books on the subject.

Would she have had the customary visit to (or from) MoD to discuss 'how we like our military inquests to be conducted' ? We know the Coroner accepted the blandishments of MoD's barrister and rejected the idea of an Article 2 Inquest. That suggests it has already been accepted as an isolated accident with no previous, unless she decides to change her mind.

Will any potential court cases depend on outcomes of the Coroner's Inquest and the verdict ?

Did the Hawk T1A have a valid Safety Case in March 2018 ?

Does the Hawk T1A currently have a valid Safety Case ?

LFH
...

dervish

9th Sep 2021, 07:54

I have just finished the revised and updated book. A revelation, more so than the original if that is possible. Why were the new images it includes from the crime scene not in MoD's report? The one with XX177's drogue shackle, next to another, shows just how much effort was required when overtightening the nut and bolt. The image of properly assembled shackles shows just how much clearance was built in to the design. And Martin-Baker supplied a special tool kit, with the correct spanners, which was not used. Instead, a socket and ratchet wrench. How the hell did this get left out of the report? Highly recommended.

falcon900

9th Sep 2021, 09:33

This travesty of justice was perpetrated by the accused, the prosecution, and the judiciary. All three were fully informed of the evidence that Sean Cunningham died due to the Gross Negligence of the MOD and the RAF High Command (to all intents and purposes, one and the same). MBAL cynically went along with this farrago, as tuc reminds us, for purely commercial reasons. In doing so they have set back a golden opportunity to reveal the VSO cover up standing in the way of UK Military AIr Safety reform. Ironic, given the lives saved by their products over more than three quarters of a century. All lost in a thrice. Those whom the Gods wish to destroy....

I think the judiciary should be excluded from criticism here. The Judge can only try the case before them, and dont have a remit to seek out the answer to all related questions. The case brought before the court was against MB. They had proper legal advisers and deliberately elected to plead guilty. The Judge doesnt seem to have been hoodwinked in any way, and her comments indicate that she fully understood what was going on, but was powerless to stop it.

On the other hand, how DPP could single out MB, and only MB, to prosecute is a truly remarkable turn of events..........

As for the new evidence, it seems merely to further substantiate the conclusions which were already all too obvious to everyone, except apparently the DPP.
It is difficult to see how the family could go after anyone other than MB, who are the guilty party of record, and while this may yield a financial outcome, it would do nothing to address the underlying issues. A judicial review of the DPPs actions on the other hand.....?

Lordflasheart

9th Sep 2021, 10:04

...
My understanding is that the DPP had no part in the trial of MB.

In very simple terms, and within limits, certain organisations are empowered to bring their own prosecutions - including the HSE, RSPCA and the Post Office. Therein lies much of several contemporary problems.

LFH

Chugalug2

9th Sep 2021, 10:47

Indeed, LFH, this prosecution was brought by HSE in the knowledge that the seat had been improperly serviced in situ, IAW an illegal servicing instruction. The RAF/MOD were fully aware of the MBAL servicing requirements and chose to ignore them. As to the Judiciary in general, and the judge in particular, the appointed judge, Sir Charles Haddon Cave, author of the Nimrod Review, chose to excuse himself pre trial. His replacement, Mrs Justice Carr,

f900:-
doesn't seem to have been hoodwinked in any way, and her comments indicate that she fully understood what was going on, but was powerless to stop it.

Really? If a conspiracy to pervert the course of justice was being played out before her very eyes, she was powerless to stop it? Was it not her duty not to let that happen? How about declaring a mistrial that would focus attention both on the prosecution and defendant? One or both of them might then have reconsidered their stance before playing out the same game before a third judge.

tucumseh

9th Sep 2021, 11:40

It is difficult to see how the family could go after anyone other than MB, who are the guilty party of record, and while this may yield a financial outcome, it would do nothing to address the underlying issues. A judicial review of the DPPs actions on the other hand.....?

If further proceedings were considered against MB, the obvious difference would be that previously suppressed evidence, now in the public domain, would be considered. It wouldn't get to court, as any solicitor would point out to the complainant that MB had nothing to do with it, and that the Judge's remarks, the SI report, and MoD's regulations, made this crystal clear. There can only be one complainant here, and the family are well aware of who is to blame, saying they were 'appalled' at MB being prosecuted.

Then...? I don't know. A legal review, similar to the Nimrod and MoK Reviews? (Good examples, as the same evidence would be produced). It was asked before the trial if MB could call Haddon-Cave as a witness. I assume MB didn't want that, as they needed to get the case out of the way by a certain date. In any case, their specialist aviation legal firm had never heard of the Nimrod Review (!), so would take ages to get up to speed.

However, the police have an enduring duty to consider new or fresh evidence. Here, Lincs Police have refused, their Chief Constable ruling that unless directly affected by the alleged offence, one is 'not permitted' to lodge a complaint. This has been upheld by the Independent Office for Police Conduct. Similarly, the Health and Safety Executive (the Prosecution). They are not required to take evidence from witnesses, and were permitted to ignore evidence disclosure rules. Like MoD, they are allowed to judge their own case.

At a more basic level, these things cost money; and it is normal for MoD to limit compensation to that of legal costs, subject to a Non-Disclosure Agreement. My guess is the family is not sitting on a pile of compo. And the firm that originally represented them now has a conflict of interest - something that also arose during the Mull of Kintyre case. Likewise, individuals and companies who would have been able to speak for MB at trial are under NDAs to the HSE.

RetiredBA/BY

9th Sep 2021, 11:57

OK, so the Judge had to accept that MB pleaded guilty, BUT , if because of evidence put before her suggested, clearly convinced her, from her statements, that some dishonesty was being peddled, why the fine of £1,000,000. Would not a fine of a nominal £1 been totally sufficient ?
No doubt the legal eagles will shoot down that argument, but I am utterly convinced that there is something rotten going on at MOD and RAF , and REAL justice has NOT been served.

…… and yes, I have read “ Their Greatest Disgrace” and I have just received the revised edition of Red 5.

Easy Street

9th Sep 2021, 18:24

Lincs Police have refused, their Chief Constable ruling that unless directly affected by the alleged offence, one is 'not permitted' to lodge a complaint. This has been upheld by the Independent Office for Police Conduct. Similarly, the Health and Safety Executive (the Prosecution).

Does there have to be an accident for an offence to be committed? I'm just wondering if anyone who flew in a Mk10 seat could make the necessary complaint against the MOD, on the basis of having negligently been put at risk by incorrect maintenance procedures.

tucumseh

9th Sep 2021, 19:54

Does there have to be an accident for an offence to be committed? I'm just wondering if anyone who flew in a Mk10 seat could make the necessary complaint against the MOD, on the basis of having negligently been put at risk by incorrect maintenance procedures.

If someone did, they'd only have to quote the Judge's remarks, as this was a key element of the alleged offence:

"By this breach MBAL exposed each RAF pilot [and any passenger] flying a Hawk to a material risk."

She had to refer to Martin-Baker, so to aim the complaint at MoD you'd (e.g.) submit the fact that MoD declined to mitigate the risk in 1984 when the Gas Shackle was designed, and there was no safety case.

dctyke

9th Sep 2021, 21:51

Bottom line is that this accident would never had happened if the RAF had maintained ejection seat bays. Prior to bay shutdown the shackle was always fitted/released by operating the barostatic release unit and opening the scissor shackle. This could not be done first line so a frig was devised.

dervish

10th Sep 2021, 11:59

dctyke The book makes that very point in Chapter 25. Seat bay closure was part of a 40% savings over a 21 month period, immediately following the 20% over 4 years that Hadden-Cave criticised. The author asks if the impact of the 20% was assessed before taking the 40%. An excellent question I thought.

Mr N Nimrod

10th Sep 2021, 12:24

Does there have to be an accident for an offence to be committed? I'm just wondering if anyone who flew in a Mk10 seat could make the necessary complaint against the MOD, on the basis of having negligently been put at risk by incorrect maintenance procedures.
no, there does not have to be an actual accident for an offence to be committed, the exposure to the hazard, risk or danger is an offence - depending of course on the exposure and degree of risk. It would be probably be compounded if the risk was not properly understood or communicated. HSE’s R2P2 explains all of this quite well.

tucumseh

11th Sep 2021, 04:26

no, there does not have to be an actual accident for an offence to be committed, the exposure to the hazard, risk or danger is an offence - depending of course on the exposure and degree of risk. It would be probably be compounded if the risk was not properly understood or communicated. HSE’s R2P2 explains all of this quite well.

Quite correct. The HSE's case was that it WAS compounded because MoD did not understand the risk (even though admitting it did) and MB not communicating the risk (even though verbal, written and video evidence proved they did).

(Here, we must differentiate between what the corporate MoD knew, and the carefully selected single witness who said he didn't understand - because he hadn't been trained. The HSE's case was that MB remained liable for providing this training, and compensating for MoD's cut-backs, even after their contract was cancelled in 1983).

In her remarks the Judge claimed she had not read this evidence, supplied by the public. But it was obvious from her remarks that she HAD read at least some of it. What she didn't explain was that the same evidence had been sent to her by the original Coroner, Stuart Fisher. I'm told by a QC that, while she did not have to read the public submissions, she did have to declare what she did read; and that she would be very unwise to ignore the Coroner, whose submission to her made it very clear he had been misled in 2014.