Inquest - Corporal Jonathan Bayliss RAF

[Lordflasheart]

...
The inquest into the death of Corporal Jonathan Bayliss will resume on 2nd November 2021 -

Council Offices - Shire Hall Street, Caernarfon.

Full Inquest scheduled for four days.

https://www.pprune.org/military-aviation/626235-hawk-xx204-service-inquiry.html

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[Lordflasheart]

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Who speaks for the Dead ?

The inquest resumes next Tuesday, Nov 2nd - with four days scheduled.

The separate interest groups will likely include -

MoD, who will not be keen for the inquest to consider the long list of repeat failures identified in various SIs and other inquiries, which despite frequent assurances at events like this, seem never to have been fixed. MoD will likely have instructed their barrister to steer everyone away from that sort of embarrassing stuff.
The pilot, who appears to be legally represented.
The family of Corporal Bayliss, who so far seem not to be legally represented, and who would be better served if this were an Article 2 Inquest - which might also have triggered legal aid.
The Public Interest

One hopes the coroner will have summoned a suitably qualified and responsible witness, senior enough to answer questions and tell the truth about the Hawk Mk1 Safety Case etc, and senior enough not to feel threatened by a disciplinary.'Etc.' includes for this purpose, answering questions about the multiple shortcomings and unimplemented SI recommendations from inter alia, the Valley (2018) and Scampton (2011) accidents.
It will also include answering pointed questions about the relevant Risk Register and any possible more recent assessment of the Risk to Life and Duty of Care, both historical and post March 2018, in particular for the back seat carriage of ad hoc joy-riders and ground engineers who have been chosen to be trained as members of the Reds 'circus.'

That presupposes there will be anyone attending the inquest who will know the right questions to ask, and with enough clout to extract truthful answers.

Or will the coroner have to settle for well rehearsed assurances by some uniformed (or did I mean uninformed ?) lackey, that these accidents have already been fully investigated and lessons have been learned and she doesn't need to worry her PLH about technical details ?

That brings us to the question of Article 2 Inquests. It would seem from press reports of the pre-inquest hearing in May 2021, that the MoD barrister successfully argued against an Article 2 Inquest. He has probably been briefed to avoid anything more complicated. I think he said previously something simple like 'the aircraft stalled - that's it.' Well he would say that, wouldn't he ?

Is the inquest likely to become adversarial ?

If the MoD claims that the MoD, the procedures and the Risk Assessment are not to blame, who does that leave ? Fate ? Bad luck ? Corporal Bayliss ? The pilot ?

Whatever the outcome, Jon Bayliss didn't stand much of a chance on 20th March 2018.

LFH
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[dervish]

Between your post and comments elsewhere, you've pretty much nailed it Flashy. The Coroner's been misled, and MoD doesn't want their past form examined. I wasn't sure what "article 2" meant so had a look see. She must have been high. Is she really saying there is no possibility of MoD having breached their duty of care? Even the service inquiry report admits it.

[WB627]

Is there any possibility that a Barrister who understands the issues could be found to represent the family on a Pro Bono basis?

[Old-Duffer]

Seems like a case for 'crowd funding' a legal eagle. Where's Gilbert Blades and his clan when you need them? (I expect Blades senior is counsel to St Peter by now)

O-D

[tucumseh]

Is there any possibility that a Barrister who understands the issues ?

This, I think, is a key issue. Very few do, which has been all too evident at many a military Inquest, with them unable to pick up when MoD has lied under questioning. Hercules XV179 is the obvious example in England.

One of the deceased was Australian, where government policy is to fund legal representation for the bereaved. The family QC was superb. He had his experts on speed dial for advice during recesses. Even so, when the porkies came thick and fast it was difficult. It was only after the event that the evidence of one senior officer could be dissected, and proven entirely wrong. By then it's too late. And, of course, MoD arranged for one potential witness, a retired C-130 pilot, to be detained on the steps of the courthouse by security forces. Not dissimilar from the Cunningham case, when Mr C was physically dragged away when he tried to speak to those who were there to help. It's not just lack of representation that's the problem. It's the system tolerating this level of interference with due process.

Hopefully, Mr Bayliss and his family have expert help next week. One of the odd things (in my opinion) is that the well-known firm who usually provide a solicitor pro bono to the bereaved, are representing the pilot. That narrowed the family's options, but they were still initially represented. This abruptly ceased after the ruling that it was not to be an Article 2 Inquest, and they were not represented at the Pre-Inquest Hearing earlier this year.

EDIT: Apologies, but I should make it clear that I think the senior officer at the XV179 Inquest was misled by briefings into misleading the court. The main lie was that, earlier in the proceedings, MoD denied ever knowing about Explosion Suppressant Foam, despite it being called up in mandated airworthiness regulations. Two MoD ESF specifications from 1971 were provided by a witness to the Coroner and Oz QC. Coroner David Masters accepted this evidence. tuc.

[Chugalug2]

tuc :-
What price the military covenant?

Indeed, tuc. Here we see all the safety nets that might assist in helping to search out the truth; various Service Charities, Article 2 Inquests, Informed Pro Bono lawyers, all seemingly unavailable to the family of Cpl Bayliss. They are left at the mercy of the RAF/MOD, which will be merciless unless checked in its tracks by the Coroner (who confirmed that Article 2 would not feature, I understand). This situation could be repeated ad infinitum unless the attitude of the Establishment changes.

In short, your loved ones could be treated with the same lofty contempt if you are currently serving.

[Lordflasheart]

...
The Enemy IS the State ......

Corporal Bayliss should not have died. His death was wholly avoidable. Under the circumstances, he didn't stand a chance.

MoD through their barrister, persuaded the relatively inexperienced coroner that it should NOT be an Article 2 Inquest. One aspect of that decision seems to be that the coroner is thereby limited to the bare facts of the death and unable to apportion blame or civil or criminal liability .... though a narrative verdict can be delivered.

In the case of an Article 2 inquest, the coroner can consider 'system neglect.' This is sometimes referred to as a 'Middleton Inquest.' That is where we should be at.

Is the inquest likely to become adversarial ?

Regardless of any procedural limits on the coroner, I feel sure that won't prevent the MoD barrister pointing fingers - and you can be sure he won't be pointing fingers at the MoD who pay him.

MoD will know that if it were an Article 2 inquest, it would be MoD under scrutiny.

A 'defendent' who hoped to be found not guilty, would be unwise to admit guilt even to their defence counsel. Thus MoD has probably made great effort to limit what their own barrister knows about the case.

Jon Bayliss paid the ultimate price, which cannot be refunded. Whether or not MoD has paid, or will pay anything to the 'family' possibly under NDA, that can't replace their loss.

It would be difficult, but in the feverish atmosphere of the coroner's court, not impossible, to point a non-aviation no-holds-barred finger at Jon, sowing only tiny seeds of suggestion that 'he might have realised ....' You only have to consider what rubbish can appear in the national press about aviation matters. If the family are not represented, that would only leave the coroner to speak up.

So if MoD has it's way, that really only leaves the pilot. It might even be to the benefit of the pilot for this to be an Article 2 Inquest. He may be just as much a victim - of the rotten system that rules his flying, if the MoD barrister has been instructed that in extremis, he is to do a hatchet job. I think he said previously something simple like 'the aircraft stalled - that's it.' He would then ask 'Who stalled the aircraft ?' You can see where this might lead.

Article 2(1) of the ECHR states: “everyone’s right to life shall be protected by law”. That places two substantive duties on member states:

1. A negative obligation to refrain from taking life

2. A positive obligation to take appropriate measures to safeguard life.

It seems in this case that substantive duties under Article 2 (point 2 above) have been breached. That is why it should be an Article 2 Inquest. It is not too late.

However, switching to Article 2 would require a substantial adjournment to be declared next Tuesday, Nov 2nd. That would be terribly inconvenient for some of the parties who want this out of the way, before it gets any worse. .... The coroner has been quoted as saying she would keep it under review. It is within her power. It is not too late.

LFH
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[Lordflasheart]

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Risk Assessment and Duty of Care - Big Cheese Holes and the Big Cheese

Corporal Bayliss should not have died. His death was wholly avoidable. Under the circumstances, he didn't stand a chance.

From the SI - He did not receive some of the listed training expected for newly selected circus members which elevated the risk. Such that the SI recommended the DDH should mandate a formal training syllabus. Under the circumstances, that issue probably made little or no difference to the fatal outcome.

From the SI - The pilot was distracted by certain issues beyond his control, including a simulator ride at Valley between flights, being required to carry out flight manoeuvres that arguably were incompatible with a shakedown flight for a prospective circus member, misjudging the flight path, losing control and ejecting. Under the circumstances, those 'overwork' issues probably made no practical difference to the fatal outcome.

The path leading to Jon Bayliss' death was laid down many years earlier. Someone would eventually come to grief.

The foundation was the systemic, blind belief that the risk involved in routine and frequent carriage of any non-aircrew in the back seat of a Hawk T1 (especially with the elevated risk associated with certain flight activities) could be passed off as Low and Tolerable and ALARP.

In principle, it's a little bit like building V-Bombers, where only certain crew members were provided with ejection seats. Was the risk deemed to be Tolerable and ALARP or whatever it was called in those days ? Or was it passed off as "Rien ne peut être fait. C'est la guerre froide" ?

Many relatively minor shortcomings in technical and training records, administration and oversight were listed in the XX 204 SI. More serious shortcomings were identified in the SI for XX177 (like absence of a valid Safety Case and the length of time taken to locate and obtain important documents from the multitude of agencies with fingers in the Hawk Pie. Similar issues for other Hawk crashes. And as regularly mentioned and warned, even to the NW Wales Coroner, a long list of serially ignored recommendations, while lying to successive inquests, inquiries, courts etc., that 'lessons have been learned and all recommendations have been implemented.'

Among all the fancy risk assessment data, including as shown in the risk register at the time of XX177 ten years ago, and doubtless up to XX204 in 2018, I could find nothing that discussed or questioned the fundamental issue of why any passenger or supernumerary crew member must be seated in the back (as opposed to anywhere else.) Nothing even to suggest that the seat-specific risk had been considered or had achieved the magic words 'Low and Tolerable and ALARP.'

Everyone in the Hawk and Red Arrows world should know about the command ejection system as fitted to the Hawk T1. Hawk T1 was designed as a trainer, where the command pilot ie the Instructor, would be the GiB, and command ejection could only be initiated 'from the back.' If the command pilot is in the front (as for most Hawk T1s these days, command ejection must be switched off. You can't currently switch 'command' from back to front. Neither can you allow an unqualified back seater the ability to initiate ejection for both seats.

That leaves the back seater to make his/her own 'in extremis' decision to eject, whether ordered or not. What happens when the front seat command pilot of a doomed Hawk T1 shouts "Eject ! Eject ! Eject !" and the back seater doesn't go ? .... How long would you give it ?
**************************************...................... ................................
Why did this specific risk assessment (if any) apparently stop where it did ?

With XX204, the SI begins to open up that discussion at last.

Recommendation 1.5.6 Page 1.5 - 2

f ) "RAFAT DDH should ensure that Circus are only employed as Supernumerary Crew on sorties that are directly associated with their primary role and not exposed to potentially hazardous flight profiles .... "

Analysis conclusion 1.4.477. Page 103

"... "Simulations indicated that if a front seat-initiated command eject system had been in place then both individuals might have vacated the aircraft before ground impact."

1.4.482. Two Aggravating Factors. (page 103)

a. The engineer's lack of experience to independently initiate his own ejection.

b. The lack of a front seat-initiated Command Ejection system.

1.5.2 Recommendations - "AOC 22 Gp should ....

e. Assess the feasibility of the incorporation of a command eject capability into the Hawk T Mk1 that would allow aircraft commanders to initiate the ejection for occupants from either cockpit seat."

And from the Convening Authority Comments - dated April 2019

NB The Convening Authority DG DSA post holder in March 2018 was Maj Gen Felton. Since March 2019, DG DSA is AM Gray. I have no knowledge of which DG wrote the comments to SI XX204. Bear in mind the comments were written when it was believed Hawk Mk 1 would be in service until 2030. You can see how the landscape might be changing ...

1.6.11. " ... The rationale for engineers to be Supernumerary Crew and deliver engineering support away from RAF Scampton is clear. Nevertheless, their employment in such a capacity should only be on sorties that are directly related to their primary role."

1.6.12. "... With aircraft commanders in all 3 main Hawk T Mk1 squadrons predominately occupying the front cockpit seat, it is appropriate to assess the feasibility of a command eject capability that could also be initiated from that position. Alternatively, Defence may have to assess if the risks associated with carrying passengers in the rear cockpit of the Hawk T Mk1 are tolerable.

Two years later the Defence Command Paper announced the surprise premature retirement of C-130, BAe146, Typhoon Tranche 1, E-3D Sentry and Hawk T1. In the latter three cases a clear about face from fairly recent positive statements on out-of-service dates and arguably, for all five types, resulting in an unwelcome capability gap. Perhaps Hawk T1 is going early because MoD refuses to pay for any general mitigation. Has RAFAT managed to head off any big changes to current Circus procedures ?**********************************,,,...................... .......................................
I seems to me entirely possible that the new DG DSA has had time to review a number of safety matters and has found them wanting. Furthermore it is entirely possible she has done what her predecessors seem to have avoided, grasped the nettle and tried to rope the sacred cow. .... Consider this -

"... Alternatively, [ without front seat command ejection] Defence may have to assess if the risks associated with carrying passengers in the rear cockpit of the Hawk T Mk1 are tolerable."

As it stands, a proper assessment of risk to life and duty of care for Hawk T1 rear seat passengers, could not possibly justify a claim of Low and Tolerable and ALARP. ... Jon Bayliss' death seems to support that argument. You would have to look further for an acceptable safety assurance.

If Circus has to travel, why not in the front seat ? If that is unacceptable to RAFAT, rather than pandering to the sacred cow, declare that it is equally unacceptable to continue with the current arrangements and another safer mode of travel will have to be found. Perhaps that discussion has already taken place. If so, what was the outcome ?

Other notable national aerobatic teams use support air transport as a matter of course, albeit many because their aircraft are single seaters. MoD knows this well because last year they sold a spare C-130J to the US Navy for their Blue Angels, (to be flown by the USMC in pretty Blue Angels colours and Marine Corps markings.

MoD has several C-130s and BAe146s for disposal. Re-cycling one or two of these might be cheaper in the long run than having a more expensive repeat of XX204.

However, there is no public indication (since 2018 and even now) that anything has actually changed (or is about to change) in terms of Red Arrows Circus seating or command ejection or alternative travel arrangements.

If no change is envisaged, that would be to publicly abandon any pretence of safety concern for this particular issue. That might suggest that DG DSA has either followed the laissez-faire or lost the battle.

If I were the NW Wales Coroner, in the Public Interest I would declare the Bayliss inquest to be Article 2. I would also summon the DG DSA, the Big Cheese herself, who might even welcome the opportunity to spill the beans in public, though it might put a damper on her career.

Jon Bayliss should not have died. His death was wholly avoidable. Under the circumstances, he didn't stand a chance.

Immediate Action to prevent a repeat would deliver a measure of justice for his family and for his memory, and would clearly be in The Public Interest.

Who Speaks for the Dead ?

LFH
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[longer ron]

If Circus has to travel, why not in the front seat ?

Not possible in a Hawk T1.
Although the rear cockpit has enough controls to land a Hawk,only the front cockpit has the LP Fuel C0ck,Parking Brake and other stuff such as the Main Flap controls,electrical switches and some Radio (?) controls.

[Moi/]

Not possible in a Hawk T1.
Although the rear cockpit has enough controls to land a Hawk,only the front cockpit has the LP Fuel C0ck,Parking Brake and other stuff such as the Main Flap controls,electrical switches and some Radio (?) controls.

​​​​​​That's not the reason not to, all that can be fixed with modifications, some very extreme; such as correcting the command eject, so the rear goes with the front. I suspect a very small modification, uncostly for 13 aircraft though.

I sense it's all down to £££.

[longer ron]

Not a small modification for the cockpit controls Moi,changing the command eject system would possibly have been more viable.

[Lordflasheart]

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Thanks Ron and Moi -

That would make sense - similar for the Gnat before. It really limits the options to command eject Mod or not at all.

I wonder if British Aerospace ever offered MoD the option to modify Hawk T1 for command ejection from either seat ? ... If not, why not ?

Did MoD refuse what would have been a sensible offer, using the same pathetic excuse that they used to refuse Martin Baker's proposal for fitting the Gas Shackle to Hawk ejection seats ? ... While taking it for Tornado ?

Deaths inevitably follow every case of inappropriate or plain daft decisions (like so many others) made in the safety of the office.

LFH
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[Lordflasheart]

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From North Wales Live - Amelia Shaw - this evening

https://www.dailypost.co.uk/news/north-wales-news/red-arrows-engineer-clearly-breathing-22038712

"At the pre-inquest hearing earlier this year Ms Sutherland came to the decision that article two of the European Convention on Human Rights - the right to life - had not been engaged. (https://www.dailypost.co.uk/news/north-wales-news/death-red-arrows-airman-raf-20599854)

But today she said that, following further disclosure from the Ministry of Defence, the "low threshold has been met for article two" to be engaged due to "breaches in duties".

Excellent start. I wonder what she will turn up next ?

LFH
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[NutLoose]

Telegraph article

https://www.msn.com/en-gb/news/uknews/man-died-after-red-arrows-jet-crashed-in-ball-of-flames-seconds-after-take-off/ar-AAQfhps?ocid=mailsignout&li=AAnZ9Ug

[dervish]

"Katie Sutherland, the coroner, said the inquest - which is expected to last four days - would look .... what recommendations were made following other air crashes involving the Red Arrows in 2011."

Seen that link to the Flt Lt Cunningham case posted here on pprune a few times over the past 2 or so years. BZ

[Lordflasheart]

...
Did BAe offer MoD a Hawk Mk 1 'switchable' Command Ejection Mod ?

According to the multitude of media reports from the inquest yesterday, there was lot of stuff about the lack of command ejection from the front seat.

But nothing to say if MoD had been offered and rejected the 'switchable' command ejection mod for Hawk Mk 1 ? I imagine if it was the other way round, we would have been told LaC by now. So far, silence.

The issue was commented on by the DG DSA herself in Part 6 of the XX204 SI, so I would be disappointed if the question had not arisen.

Will anyone at the inquest ask ?

LFH
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[Out Of Trim]

How about the Hawk T2? We’re any changes to Command Ejection made to that version?

[teeonefixer]

As I understand it, Martin Baker are the DO for the seats on the TMk.1 under contract from the MoD, so BAE Systems are not directly involved in any mods until they get actioned and the installation changes (wiring/switches) need to be designed. The TMk.2 seats are under a different contract arrangement.

[CAEBr]

How about the Hawk T2? We’re any changes to Command Ejection made to that version?

The command ejection system on the T2 (which remains an MBA system) is unchanged from other Hawks. The only seat change was the introduction of arm restraints at the MoD's specific request and cost (having been assessed as unnecessary by both MBA and BAES). The use of arm restraints were raised in a much older T1 Service Inquiry with the RAF never showing an appetite to fit them on the T1 fleet preferring to then highlight the discrepancy by fitting them to the T2.

CAEBr

[Lordflasheart]

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TeeOne and CAEBr - Thanks, that all makes sense. IIRC the ARLs came from the Kastelli mid-air in 2010.

The major medias seem to have lost interest, but from Wales on-line this arvo ...

https://www.walesonline.co.uk/news/wales-news/red-arrows-crash-fatal-ejected-22072171

"An inquest in Caernarfon (https://www.walesonline.co.uk/news/wales-news/red-arrows-crash-fatal-ejected-22044443) on Thursday was told 25 recommendations had been made following a Defence Safety Authority Service Inquiry into the crash.

Group Captain Jackson said a feasibility study had been carried out and confirmed the system could be changed so pilots in the front seat could eject a passenger.

He said: “The feasibility study was completed by Martin Baker and it was deemed, yes, it could be incorporated into the aircraft.”

He said the improvements were expected to take between two and three years once the business case was approved."

Manana ?? .... I don't think we have anything quite so urgent as that in our MoD dictionary.

I bet Jacko is wondering what sort of poisoned chalice he's been landed with. They were talking about this problem in the Hawk Risk Register back in 2012, when 'e'd 'ardly got 'is scraper. He's now Hawk DDH and CO Hawk Wing.

LFH
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[tucumseh]

[b]...
Group Captain Jackson said a feasibility study had been carried out and confirmed the system could be changed so pilots in the front seat could eject a passenger.

He said: “The feasibility study was completed by Martin Baker and it was deemed, yes, it could be incorporated into the aircraft. He said the improvements were expected to take between two and three years once the business case was approved.”


There's so much wrong with this statement I don't know where to begin.

Even if we ignore that fact he implies nobody recognised the risk until March 2018 (which would be untrue), why has a feasibility study taken over 3 years? Martin-Baker and BAeS will have known exactly what was needed, or else neither deserve their status as a Design Authority. Why has his office junior not self-tasked, identified funding, written the business case, and submitted it for approval within, at most, a few weeks? Instead, the witness is talking about 6 years and more from the accident to mitigation, by which time the T1 will be gone, except a few at the Reds which will presumably need a waiver as the timescale will start impingeing on the remaining useful life rule.

I'm afraid that, once again, an unfortunate MoD witness is reading from a script, probably written by those who are meant to have done the job, but don't actually realise this.

This all comes under 'maintaining the build standard', which is a prerequisite to a valid safety case, and permitting service regulated flying. It might be a good idea to start doing it again.

[CAEBr]

IIRC the ARLs came from the Kastelli mid-air in 2010.

I think actually they first raised their head after XX186 in 1998.

[Background Noise]

I think actually they first raised their head after XX186 in 1998.

And well before that, after the loss of XX298 in 1984.

[Lordflasheart]

Broken arms and dislocated shoulders ?

Perhaps following from "Where are my arms after I pull the SPFH ?" as opposed to "Where are my arms after I pull the Face Blind handle ?"

[Lordflasheart]

Hawk Risk Register - Fatigue Risk and mitigations

According to the multitude of media reports from the inquest, there has been a lot of generalised stuff about fatigue, referenced to Reds pilots.

SI - Page 1.4.70 (1.4.301.)

"The Sqn Chain of Command (CoC) maintained oversight of personnel fatigue .... The only time that a senior pilot had seen R3 fatigued was 2 weeks before the accident ..... . On that occasion R3 had removed himself from flying. "

SI XX204 Conclusions Page 1.4.102

"1.4.473. The Panel determined that when considered collectively it was very likely that R3 was, to a degree, fatigued, ... "

Contributory factors Page 1.1.103

g. ... "The pilot's working routine was detrimentally affecting his morale, not allowing him sufficient time for rest, consolidation and affecting his fatigue levels."

h. ... "Pilot fatigue." ****************************
...
According to an historic Hawk Risk Register, two fatigue risks had been identified, which required specific mitigation to become Low and Tolerable and ALARP.

I can find no mention in the SI of these specific risks or of the required mitigations.

They were referred to in 2012 as 'Cumulative fatigue' (RED/CFIT-PILINC/02) and 'Fatigue' (RED/STFBS/01. Those responsible were listed as the DDH and the Wg Cdr RAFAT.

Are these risks and mitigations still valid and in force ?
Are these issues included in the coroner's reference to 'breaches in duties' ?

LFH
...

[4mastacker]

Forgive my intrusion to this thread, but something has crossed my mind that may be pertinent to the discussion.

I was stationed at Scampton when Sgt Inman ejected from a Red Arrows Hawk (XX227?) during a transit flight from Macrihanish to Kinloss. ISTR, during a discussion with a member of the Red's 2nd line team not long after the incident, the question was asked why the pilot wasn't also ejected when Sgt Inman left the aircraft and he replied that the Red Arrows aircraft differed from the rest of the Hawks in the fleet in that the command ejection was initiated from the front seat.

[Background Noise]

... and he replied that the Red Arrows aircraft differed from the rest of the Hawks in the fleet in that the command ejection was initiated from the front seat.

All wrong I'm afraid. They are all the same and the rear can (selectably) command eject the front seater but not the other way round. Originally on the premise that the main role would be pilot training with the instructor (aircraft commander) in the back seat. The aircraft role has expanded somewhat and there is little if any student instruction left. That is (one of) the points of this argument.

[tucumseh]

To paraphrase the Red Arrows' risk register. If command eject is on, and the passenger ejects both inadvertently, then the risk is of injury (not death according to MoD) to both. The 'tolerable and ALARP' mitigation is to have command eject off, so that only the passenger is injured.

But, as admitted at the Inquest last week, it's not ALARP, and I'm sure the Bayliss family don't think it tolerable.

This admission by MoD is, presumably, one reason why the Coroner adjourned. Another might be that a senior officer stated quite categorically that Bayliss should NOT have been in the aircraft.

[teej013]

https://cimg7.ibsrv.net/gimg/pprune.org-vbulletin/767x183/hawk_command_control_valve_01db1f0605f9ed736f97b522ae3eb62cb b548212.jpg

[ROC man]

Daily Telegraph letters yesterday:Too risky a manoeuvreSIR – An inquest has been considering the death of a Red Arrows engineer (https://www.telegraph.co.uk/news/2021/11/03/raf-pilot-speaks-eternal-regret-ejecting-without-engineer-perished/), Corporal Jonathan Bayliss, at RAF Valley in 2018.

When I saw the footage and read the report of the crash, my reaction was that the pilot was practising a “turn back”. This manoeuvre is questionable in its efficacy and carries a high risk; the aircraft is on the cusp of the stall throughout and, given the aerodynamics of the Hawk wing, once it goes wrong, there is no way out.

As Officer Commanding Flying at RAF Chivenor in 1992, I was involved in the board of inquiry into an identical accident in which a young weapons instructor student died because he, too, failed to eject – why we’ll never know.

The inquiry was thorough, but the outcome was clear: the aircraft stalled and recovery was impossible, given its height, so the crash was inevitable.

At the conclusion of the inquiry, I wrote that, given the risks, and as a turn back had never been done for real, I recommended that practising the manoeuvre be discontinued.

I was, however, overruled by the powers that be, who stated that “it was a good judgment exercise” and should remain in the syllabus.

Three months later, a Hawk was written off at Valley following a practice turn back, although both pilots walked away from it. Twenty-six years later, sadly, Corporal Bayliss lost his life, and it could have been avoided.

Wg Cdr Jeremy Parr RAF (retd)
Suckley, Worcestershire

[Dominator2]

ROC man
When I saw the footage and read the report of the crash, my reaction was that the pilot was practising a “turn back”. This manoeuvre is questionable in its efficacy and carries a high risk; the aircraft is on the cusp of the stall throughout and, given the aerodynamics of the Hawk wing, once it goes wrong, there is no way out.

As Officer Commanding Flying at RAF Chivenor in 1992, I was involved in the board of inquiry into an identical accident in which a young weapons instructor student died because he, too, failed to eject – why we’ll never know.

The inquiry was thorough, but the outcome was clear: the aircraft stalled and recovery was impossible, given its height, so the crash was inevitable.

At the conclusion of the inquiry, I wrote that, given the risks, and as a turn back had never been done for real, I recommended that practising the manoeuvre be discontinued.

I was, however, overruled by the powers that be, who stated that “it was a good judgment exercise” and should remain in the syllabus.

Three months later, a Hawk was written off at Valley following a practice turn back, although both pilots walked away from it. Twenty-six years later, sadly, Corporal Bayliss lost his life, and it could have been avoided.

Wg Cdr Jeremy Parr RAF (retd)
Suckley, Worcestershire
I think that maybe Jerry is wrong?
My understanding is that the Practice Engine Failure was initiated with "apparently" enough height and speed to get to Low Key. Once the pilot had failed to achieve that Gate the Practice should have been "Knocked Off".
The poor decision to continue put the aircraft into a continually worsening situation. Even at half way round finals the aircraft could have been flown away quite safely.
The fact that the Hawk T1 does not had an AoA Gauge, Stall Warner or Command Eject Front to Rear only made the outcome more inevitable.

[4mastacker]

All wrong I'm afraid. They are all the same and the rear can (selectably) command eject the front seater but not the other way round. Originally on the premise that the main role would be pilot training with the instructor (aircraft commander) in the back seat. The aircraft role has expanded somewhat and there is little if any student instruction left. That is (one of) the points of this argument.

Thank you for that reply. I must say that I'm surprised that someone who worked on the Red's aircraft appears to have given out inaccurate information - I wasn't in a position to contradict what he said.

[Background Noise]

ROC man

I think that maybe Jerry is wrong?
My understanding is that the Practice Engine Failure was initiated with "apparently" enough height and speed to get to Low Key. Once the pilot had failed to achieve that Gate the Practice should have been "Knocked Off".
The poor decision to continue put the aircraft into a continually worsening situation. Even at half way round finals the aircraft could have been flown away quite safely.
The fact that the Hawk T1 does not had an AoA Gauge, Stall Warner or Command Eject Front to Rear only made the outcome more inevitable.

Sort of. A (practice) turn back (to the reciprocal runway in the examples above) is also initiated with enough energy to get back to the runway. Both however, can go wrong quite quickly and it is then down to the pilot to recognise (or not) that situation. Neither manoeuvre gets to a classic Low Key so it is impractical to use that as a gate.

[Lordflasheart]

...
Hawk (Red Arrows) Risk Register - PEFATO - Turnbacks

'Exhibit No 67 - Risk Register' - from the Scampton XX177 accident in 2011, includes some sixty separate risks and where necessary, the required mitigation.

Although the spreadsheet style register is not specifically titled, it seems reasonable to presume it is specific to the Red Arrows, because every one of the risk file names begins with 'RED/.' Each risk is required to be reviewed periodically - six months or a year, though a few are conditional.

One of the identified risks - Risk No. RED/LOCI-HAN/04 - refers to 'turnbacks.'

This risk was described as -

.... "Effect - Loss of Control during the manoeuvre ..."

.... "Worst credible outcome - loss of pilot and supervising pilot"

.... "Liklihood - remote."

.... "Severity - critical.

... "Risk level - Medium."

.... "Risk owner - DDH. .... Risk Manager - OC RAFAT.

The required mitigation to reduce the risk to 'Low and Tolerable and ALARP was in three parts -

.... i) "Bespoke turnback training by HQ CFS Exam Wing."

.... ii) "60 day currency" ... [That's one practice every two months.]

.... iii) "Requal by QFI if ... [60 day currency] ... lapsed."

I can find no mention of a Hawk or RAFAT Risk Register, nor of the specific risk, nor of the mandated mitigation, anywhere in the XX204 SI. ...... A lot of contradictory mishmash, like for instance, the table on Page 1.4 - 7. - PEFATO recency - 30 days for 100 Sqn, 60 days for 736 NAS and, unbelievably, 'Not mandated' for RAFAT.

You'd think that issue alone would have invited comment from the XX204 Board, if only to deplore the change from the mandated '60 days' only six years earlier, and given the record of accidents resulting from practicing EFATOs and Turnbacks, and including the presumption that passengers should not be carried while practicing 'dodgy' manoeuvres.

Nothing in Part 1 to say if the Risk Register was included as an exhibit or had been considered. The closest I got was this cryptic comment -

..... Page 1.4.105 Observations

...... j. ... "The DDH's Air Safety register appeared to be more of a personal record rather than a formal decision register."

Four specific problem areas listed in the Risk Register at the time of XX177 at Scampton were discussed in great detail in the XX204 SI (only six years later) but without any reference to the Risk Register or to the Risk Codes or to the required mitigations.

The specific risk codes are -

RED/OTHR-1/05 - Command Ejection. ... RED/STFBS/01 - Fatigue

RED/CFIT-PILINC/02 - Cumulative Fatigue and ... RED/LOCI-HAN/04 - Turnbacks

Was the XX204 Board unaware of the Risk Register or of the importance of (ignoring) the mandated mitigations that referred specifically to Red Arrows, whose fatal crash they were investigating ? .... Or were they told 'not to go there' ?

Or has the entire Hawk Risk Register been abandoned ?

Someone must know.

LFH
....

[Bob Viking]

I’m sure your intentions are pure and honourable but I’m afraid your posts are a tough read.

They are not especially well structured and it is often hard to understand what you are after.

In my view, a coroner is far more likely to obtain the relevant information and get to the bottom of things than a rambling poster on Pprune.

Maybe just let the lady get on with it and publish her findings in due course?

Before I face the wrath of the assembled kangaroo court I can state categorically that I have no dog in the fight.

BV

[dervish]

Lordflasheart - Thanks for your posts. In summary then, relevant risks weren't ALARP, the risk register was pants, and MoD didn't disclose this. That sums up a lot of threads here.

Bob Viking - Having taken MoD's side the coroner was persuaded to change her mind. The successful argument was posted on pprune. It's even in a book. I don't think she worked it out by herself.
If you are aircrew you have a big dog in the fight.

[Lordflasheart]

...
Dear Bob Viking,

Thank you. ... If I may, I'll start from the bottom and begin with Kangaroo Courts.

Among these I would include the disgraceful and inexplicable overturning of the Mull Chinook SI by two RAF gentlemen, which resulted in the families of your colleagues being denied compo for many years - until a bit of public rambling on PPRuNe uncovered the deep rooted technical and institutional lies that had been supported by the state for so many years.

I would follow with the Kangaroo Crown Court at Lincoln, in which MBA were unjustifiably prosecuted by the HSE, where despite MBA, the Judge and the HSE being shown the exculpatory evidence, the court was happy to accept the technical lies and MBA's spineless and inexplicable guilty plea. The subject being principally the scissors shackle/gas shackle issue which put you and your colleagues at risk for many years.

Then I would look at the Sea King collision inquest where the coroner showed no interest in the truth and the MoD lied to the families about the case. Or the C-130 inquest where MoD security officials prevented an RAF officer entering the Coroners Court where he intended to give evidence of MoD lies about ESS. It took a brave coroner - there are some - to compete with the state on that one, and probably helped with the establishment of a cadre of 'specially trained' coroners to deal with active service deaths overseas, probably encouraged by MoD who hoped to prevent more unseemly verdicts publicly blaming MoD for their secret shortcomings relating to service deaths.

Madam Acting Senior Coroner's Caernarfon predecessor, in post for fifty years, is on record as having told some PPRuNe ramblers he was not able to take account of their real evidence because they were not 'interested parties.' It was he who should have held a local inquest into a service death in Scotland, where, as I am sure you will know, it was discovered that service personnel are not considered to be employees, thus doing them out of certain rights.

One hopes Madam Coroner may have felt able to consider certain rambling information that has been submitted to her and to her predecessors, or even that she may surreptitiously read those ramblings on PPRuNe after lights out.

I hope that her about face on Article 2 will have some beneficial result for Jon Bayliss' family and for future service deaths, but I worry that it is more likely to result in her not being confirmed in post, pour encourager les autres à suivre la ligne.

So what am I after ? Relevant to the current thread, I would like to know if the Hawk (RAFAT) Risk Register still exists. If so, why was it not mentioned in the SI ? If it doesn't, what has replaced it ? As I tried to explain, there are several very relevant issues which were glossed over or plain ignored by the XX204 Board, that would not be known about without access to the (historic) Risk Register. Someone will surely know the answer.

I would also like the MoD and the State to stop trying to conceal the truth about the next few service fatalities, or even to take preventative action. I gather from your posts that you are an experienced Hawk and service pilot yourself. It might be your mates or mine next, and (who knows ?) a bit of rambling on PPRuNe might just tip the balance.

You're right - the entire subject is a tough and highly technical read. Many readers (but not boards of inquiry, coroners, barristers or interested parties who want to know the truth) might be forgiven for dozing off after the first page. Finding the truth is always complicated but fortunately, it is now well helped by modern communications, when all sorts of previously concealed evidence can pop up to confound those who would conceal. Learning the truth would be particularly unpalatable when the enemy turns out to be the state that employs you to protect it.

I'm sorry my posts seem not well structured and hard to understand - and long winded again. I didn't have the benefit of the Short Service Writing Course. There are several well written good books by an author named David Hill. I can't remember if you previously said you'd read any of his stuff, or that you couldn't be bothered to do so. I'm sure you know where to find them.

Yours sincerely, LFH.

PS. I'm not sure I do 'pure and honourable' but I appreciate your thinking I might ;)

...

[Ewan Whosearmy]

LFH

A wonderful response.

Keep posting.

[Bob Viking]

That is a great response.

I clearly didn’t articulate myself very well previously.

I wasn’t questioning your motives but just pointing out that your earlier posts were not very clear.

BV

[Chugalug2]

LFH, a real tour de force, sir! If ever I ask myself again how to best explain the stranglehold the MOD has had over exposing the scandal that is UK Military Air Safety then the answer is simple, "like wot he said!". Of course this is an arcane and complicated subject and one wouldn't reasonably expect anyone who isn't a fully trained and experienced airworthiness engineer to have a complete understanding of it. I certainly don't, but I now know far more than I ever did before, having read through the airworthiness related fatal accident threads here or, more conveniently, the various books by David Hill. If an old has been like me can do it then much younger serving aircrew can, and should! As LFH says, it is in the interests of every aviator, military or civil, to do so.

A quick trip down a tropical river is all that is necessary to understand how things should be, and how they most glaringly are not!

[Lordflasheart]

...
From the NW Wales Coroner's Office 19 Nov.

"Inquest resumption 3 December 2021, 9:30am"

LFH
...

[NutLoose]

The stupid thing is if you subvert the outcome, then your safety regime is not fit for purpose, the reason you carry out a follow up to an accident is to find the root cause and prevent it from killing some other unfortunate
If someone prevents that happening or covers it up, and someone else pays the ultimate price then they should be prosecuted for involuntary manslaughter., and until that happens nothing will change.

[Exrigger]

Pity the MOD wiggle out of being charged with Corporate Manslaughter:

https://www.cps.gov.uk/legal-guidance/corporate-manslaughterGovernment Departments Section 11(1) and Schedule 1 of the Act provide that specified government bodies can be prosecuted for Corporate Manslaughter. The statute provides an exception to the general rule that a crown body cannot be prosecuted for a criminal offence (see section 40 of the Crown Proceedings Act 1947).

Schedule 1 lists the government bodies to which the offence applies. It includes the major departments of central government such as the Department of Health, Department for Education, DEFRA, Ministry of Defence and the Home Office, as well as the Welsh Government.

Section 16 contains provisions which identify the relevant body to prosecute where functions have been transferred from one public body to another since the date of the offence.

[NutLoose]

Can an individual be charged? after all the NI trials show service personnel can indeed be charged.

[Chugalug2]

Can an individual be charged? after all the NI trials show service personnel can indeed be charged.

Past precedent would seem to indicate that if that were to be the case it would be someone of 1* or below.

[Lordflasheart]

...
Nutloose -
"... if you subvert the outcome, then your safety regime is not fit for purpose, ..."

Thank you. ... I wish more folks realised this basic tenet.

Exrigger "Pity the MOD wiggle out of being charged ..."

Useful link that.... Last I heard, it was called 'Crown Immunity' which officially got you off almost everything that was officially crooked.

Known risk of being 'done' for corporate manslaughter would easily explain MoD's determination to lie about multiple Service fatalities (as rambled about regularly on PPRuNe) and in the book "Breaking the Military Covenant - Who Speaks for the Dead ?"

The problem seems to be that corporate subversion and corporate wiggling have been going on for at least twenty seven years (Mull Chinook in 1994) so it would now take a miracle to cut out the collective institutional infection.

'Wiggling' does not even come close. If you can control the entire system you don't need to wiggle. Corporate Mutual Insurance Company - of Whitehall, London.

Let's see how brave Madam Acting Senior Coroner feels on Friday 3rd December .... If she wants to be confirmed in post ?

Dare I wonder if this might be an opportunity for a turning point, towards a bit of old fashioned honesty ?

LFH ....

NB - Chugalug - I am reliably guessing that the "VSO Risk Register" is still in force (unamended since 1994) but is only made available to Two * and above who qualify for life membership of CoMIC (of Whitehall.)
...

[NutLoose]

I used to religiously read the accident reports when in the service to learn and further my knowledge in the hope I would avoid such pitfalls, every wall in the building was plastered with flight safety information, had I known then what I was reading was a great work of fiction with half truths and blatant lies by those that should have known better, I think I might have thought why do I bother..

What was it the poster used to say,

“Flight Safety is Everyone’s Responsibility”

I obviously missed the small print at the bottom stating

“Senior Officers are exempt from the above statement.”

[tucumseh]

Briefly, the Inquest concluded today.

MoD got a kicking. Known risks not tolerable and ALARP. Failure of duty of care. Repeated failure to implement recommendations from previous accidents (even when instructed to by government).

But, these violations are not gross breaches. She did not define 'gross'.

However, she did make a point of confirming what we already know. The DSA/MAA is not independent, despite claiming it is. All things being equal, this should have far-reaching implications.

This criticism is infinitely worse than that made by any other Coroner, with the exception of Mr Walker in the Nimrod XV230 case.

[Exrigger]

While she said the pilot had not breached his duty of care, she did conclude that the MoD breached its duty and fall below the standards required, although not so far below that a conclusion of corporate manslaughter could be reached.

Ms Sutherland said: “There was a breach of duty but it cannot be said to be so bad, so gross, to warrant a criminal sanction.”


The comment quoted from the coroner explains why the MOD avoided a corporate manslaughter charge again, in isolation that is probably correct, but add all the other failures of duty of care in the not to distant past there must be a case to take some more serious action against the MOD as they do seem to avoid actually doing anything to prevent incidences repeating themselves.

[dervish]

The comment quoted from the coroner explains why the MOD avoided a corporate manslaughter charge again, in isolation that is probably correct, but add all the other failures of duty of care in the not to distant past there must be a case to take some more serious action against the MOD as they do seem to avoid actually doing anything to prevent incidences repeating themselves.

Is a Coroner not allowed to consider previous offences? Is the reason because this evidence wasn't given to the Coroner in court? I read that the family didn't have a lawyer.

[tucumseh]

Exrigger/Dervish

You both raise good points. Perhaps I can shed light…

The reason why Ms Sutherland, the Coroner, overruled her predecessor on Article 2 was the submission to her by the family that there were 12 common factors between the 2011 death of Sean Cunningham, and that of Jonathan Bayliss. She accepted the evidence that MoD had assured the Cunningham Coroner that all these issues had been, or were being, dealt with. She put this to MoD, and it admitted the ongoing breaches. Additionally, she cited another case, at RAF Mona in 2007, criticising MoD again for not reducing risks to tolerable and ALARP.

But, when considering the question of corporate manslaughter, she did not take these prior breaches into consideration, only looking at them as they applied to the Bayliss case. She ruled that these breaches (and the lies) ‘did not fall far below what can reasonably be expected of the organisation in the circumstances’. She also said that ‘there was not a sufficiency of evidence’ of MoD’s breaches (despite it admitting them).

Nor did she take not account that the same underlying breaches – refusal to implement mandated regulations, accompanied by a series of false declarations that they had been implemented – had led to scores of avoidable deaths in accidents where the root cause had been notified in advance to senior officials, officers and Ministers.
Like me you will find this strange, and I’m sure there is a proper legal explanation, or a legal nicety that I’m unaware of.

Dervish, in reply to your question about the evidence, in addition to written submissions the family raised all the above in court, and the Coroner accepted it all as true.
It is worth noting that the family did not ask the Coroner to consider gross negligence manslaughter against the pilot. Quite the opposite; they noted ‘he was as much a victim of MoD’s negligence’. It was corporate manslaughter she was asked to consider, because that is where the evidence lay. Inexplicably, in her written decision the Coroner said the family had asked her to consider manslaughter against the pilot.

[Ridger]

Vey interesting thread; such a frustrating and unfortunate case. Amidst much wisdom, I'm pleased to read some discussion around the appropriateness of the PEFATO. Notwithstanding the luxury of armchair hindsight, an operating culture which allows a fatigued pilot to fly PEFATO with ground crew in the back is going to be challenging to defend...

[dervish]

Thanks for the explanation tuc. :ok:

[falcon900]

Have I missed it, or has the media response to the MoD admitting it has lied / misled assorted coroners been subdued at best? I realise they are very busy with No 10 Christmas parties past and present, but admissions such as this are very rare, and have huge import.

[Distant Voice]

I suppose the risks associated with stall warning and command ejection will now be declared ALARP (Temporal) because some sort of modification programme is under consideration, and we will just fly on. The collision risk associated with Tornado GR4 was declared ALARP (Temporal) and we know what happened there. ALARP (Temporal) is a fudge conjured up by the hierarchy to avoid the consequences associated with an RA that states that if a risk is not ALARP then all routine flying must cease.

DV

[tucumseh]

Falcon900

Have I missed it, or has the media response to the MoD admitting it has lied / misled assorted coroners been subdued at best? I realise they are very busy with No 10 Christmas parties past and present, but admissions such as this are very rare, and have huge import.

No, I'm afraid you didn't miss anything. More or less complete silence, especially from the broadsheets. Even the local media in NW Wales pulled the plug.

It is perhaps worth noting that during the Sean Cunningham case in 2018, MoD demanded that the BBC confirm its (inconveniently accurate) line of inquiry would be dropped. They also demanded that a BBC journalist hand over all her notes on the case. The first was satisfied by senior management simply taking journalists off the story, but to her credit the young journalist refused to hand over her notes.

Which is a pity in a way. That was the day an MoD witness blurted out that safety cases are unrelated to airworthiness. The journalist's notes would have taught him a few things.

[pulse1]

Last Saturday's Telegraph offered the headline "MoD 'must act to prevent more RAF crashes". It went on to say that the MoD considered fitting stall warning to the Hawk following a previous accident in 2007 but decided not to invest in the system. Ms Sutherland said "This does give rise to concerns that future deaths will occur and action should be taken". The article said that she would recommend to MoD that stall warnings should be installed in the aircraft and better simulator training developed.

[SlopJockey]

https://www.judiciary.uk/publications/jonathan-bayliss-prevention-of-future-deaths-report/

Does anybody have links to other records?

[Dominator2]

I am at a loss as to why it is recommended to fit a Stall Warning System when an Angle of Attack Indicator with Audio Warning would achieve so much more?

Is it just that the Coroner was not adequately briefed to enable her to fully understand the problem?

[tucumseh]

I am at a loss as to why it is recommended to fit a Stall Warning System when an Angle of Attack Indicator with Audio Warning would achieve so much more?

Is it just that the Coroner was not adequately briefed to enable her to fully understand the problem?


The Service Inquiry recommended 'AOC 22 Group investigate the incorporation of an artificial stall warning capability'. (para 1.4.253)

From the Coroner's remarks, and her written decision, it would seem she was displeased that the same recommendation had been made after an incident in 2007, with nothing done. She is not trying to dictate a solution, but repeating her point that known risks are not tolerable and ALARP, and that this constitutes negligence (but not gross negligence).

Some would say negligence is negligence.

[pulse1]

Would I be wrong here to see a parallel between this inquest and that for the Nimrod? Criticism of the MoD by a coroner eventually led to the end of the Nimrod. Is it possibe that a similar outcome will bring a complete end to the Hawk Mk1 and, therefore, the Red Arrows? I can't imagine that MoD will be too pleased to set up a test project for such a limited application.

[sycamore]

Doesn`t the USN T-45 Goshawk have an AAI plus audio....?

[tucumseh]

Would I be wrong here to see a parallel between this inquest and that for the Nimrod? Criticism of the MoD by a coroner eventually led to the end of the Nimrod. Is it possibe that a similar outcome will bring a complete end to the Hawk Mk1 and, therefore, the Red Arrows? I can't imagine that MoD will be too pleased to set up a test project for such a limited application.

Exactly.

The family did cite the Nimrod Review, saying in a submission to the Coroner that the same systemic failings were recorded by Mr Haddon-Cave. But, as noted earlier, while she took past breaches into account when ruling on Article 2, she did not when considering the admitted breaches.

I suppose the main difference is that there was a Nimrod safety case, albeit not fit for purpose. Here, there wasn't one. Haddon-Cave considered the former worthy of legal action (but named the wrong people), while Ms Sutherland completely ignored it.

[tucumseh]

The Coroner's letter to Secy of State Ben Wallace setting out her 'matters of concern' makes interesting reading.

Her role is to establish cause of death. Her two matters of concern relate to cause of accident, an entirely different thing. It is seemingly of no concern that the pilot lived yet Jonathan died. Which is actually MoD's formal position.

Her stance seems to have changed once the issues raised at the Inquest were collated and sent up to the Chief Coroner. A political direction imposed upon her? She cannot help but notice the contradictions between her words of November and those of December.

[Lordflasheart]

...
Bayliss Inquest - Prevention of Future Deaths letter

The Defence Minister's reply dated 7th March 2022 is here - https://www.judiciary.uk/publications/jonathan-bayliss-prevention-of-future-deaths-report/ along with the Coroner's PFD letter.

With respect - They all seem to have completely missed the point.

The historic risk assessment and mitigation for back-seater carriage was shot to pieces by the death of Corporal Bayliss. A risk re-assessment seems to have been done since 2018, but whatever its conclusions, it clearly missed the point and has done nothing for back-seat safety.

Back-seaters, including Circus are still being carried and the only changes made so far are administrative. If MoD thinks that future 'promised' changes are enough to make continued current carriage ALARP and Tolerable, they need to think again. Alternately, they may think the paper changes and 'promises' are enough to hoodwink us.

The Coroner put up two half-hearted Matters of Concern 'in order to prevent further death' but missed the obvious elephant. She did not ask why it was considered necessary to carry Circus members on certain (or any) Hawk flights. She did not ask how the new risk-assessment of continuing to carry Circus members could be considered ALARP and Tolerable in view of the fatality and when safer alternatives were available.

The Minister replied in the same vague vein, though he did, to my surprise (because I don't remember that being promised at the Inquest) suggest - " the development of a Command Ejection capability, and ... are already in train."

The principal reason Jon Bayliss died was because he was unlucky enough to be sitting in the back of a perfectly serviceable aircraft when it happened to crash. More warning and he might have ejected when so ordered. Command Eject and he might have been successfully command-ejected by the pilot.

Why was he in the aircraft in the first place ? He was not a required member of the operating crew, thus his presence was arguably optional. He was in the aircraft because it suited some long-standing and so far unquestioned organisational agenda, as a convenient and cheap way of transporting ground crews. Also, up to now - it was probably considered great fun and a bit of a reward for hard-working and trusting ground crew who presumably did not have to be ordered to fly, or forced to join the Circus.

No matter what shuffling of paper or tweaking of simulators, the next time a pilot screws up, the back seater will still be at the same serious risk as Jon Bayliss, while there is no front to back Command Eject.

It may well be that the current Minister honestly intends to install 'front to back' Command Eject - but for a mere couple of dozen Hawk Mk 1s - what would you believe ? If the modification work is easy or inexpensive, why wasn't it done years ago ?

There are (or were) plenty of 'spare' transport aircraft which might fit the bill for routine RAFAT support. Many other national aerobatic teams fly single seaters. They don't have a problem with provision of support aircraft. The Blue Angels bought one of our 'surplus' C-130Js. Time to put up or shut up ?

Historically, for many aircraft types, practising the failure killed more folk than any actual failure. Civvy-wise, it is no longer permitted to practise engine failure on a real (air transport) aeroplane. It can only be done in a simulator. Bear in mind that a civvy aeroplane may be carrying hundreds of pax who don't have the benefit of ejector seats or parachutes and who might not use them even if ordered.

Question 1. Why is it still considered necessary to practice 'engine failure after takeoff ' in terms of what is demonstrably a challenging flight regime ? Horsing a Hawk round in the weeds with not a lot of knots has contributed to some nine crashes and four deaths since 1982. What is wrong with 'zoom and eject in comfort' ?

And in the mean time, the only way to ensure that RAFAT back-seater risk is ALARP and Tolerable - is regrettably to ban back-seat rides for all but required pilot training and assessment, at least until front to back Command Eject is in service.

Question 2. Why does MoD believe it is still safe to continue carrying non-pilot back-seaters, without front to back Command Eject ?

LFH
...

[alfred_the_great]

The bigger question: why Red Arrows at all? Is display flying ALARP?

[LOMCEVAK]

If I may add a couple of points to what LFH has posted and what is in the linked documents. I flew the Hawk T1 for over 40 years, instructed on it for 30 years and flew quite a few non-aircrew in the rear seat. I also authorised many others for the same activities.

My first point is with respect to PEFATOs. We flew these fairly regularly adhering to very specific minimum airspeeds and energy states (combinations of airspeed and height). Often, we recognised that we had insufficient energy such that we flew a go-around (and for real would have ejected). There was never any pressure to continue and if it was an instructional sortie or checkride then the required standard related to correct decision making and not actually touching down on the runway. Overall, if the SOPs were followed then I did not consider these to be particularly high risk manoeuvres and stall prevention was achieved by strictly adhering to minimum speeds and maximum bank angles. The speeds flown and the energy states during the accident manoeuvre were significantly lower than what I had ever known to be taught or promulgated. In addition, 'low key' for a low energy pattern such as this needed to be an energy state and not a geographical position with respect to the touchdown point as was usually considered for a full forced landing pattern. For continued safe operation of the RAFAT aircraft prior to any of the suggested modifications being incorporated, have the SOPs been reinforced and/or amended to take into consideration energy states and minimum speeds when engine out, for practise or for real? I am sure that they have but I have not seen any mention of this reported.

With respect to using flight simulators for PEFATO training, the pilot needs to maintain a visual sightline to the runway at all times during the pattern, and the visual systems of many simulators do not allow this (vision being limited to forward of the '3-9 line'). Therefore, if on-aircraft training were not permitted any simulator used would have to have an adequate visual system to allow the pilot to use the same visual cues as for real.

There was a significant ambiguity in the Aircrew Manual of which there has been little mention. It stated that the minimum airspeed once the gear and flaps were down was, at the accident weight, 155 KIAS (170 KIAS being the nominal airspeed). However, what it should have said was that this was the minimum speed at which to commence the flare to touchdown (in order not to stall) but some interpreted this as the minimum airspeed in the finals turn also. I consider that this ambiguous wording was one of the greatest potential risks for stalling during forced landing patterns and I always reinforced this clarification very strongly in all training that I delivered.

I do not believe that the decision as to whether non-aircrew can fly rear seat in aircraft such as the Hawk T1 is necessarily just a simple yes/no. It may be an overall no (with a potential for reducing morale and motivation for groups such as 'The Circus') but there is also the consideration that it could be a 'yes' but only for lower risk activities such as transit flights. I have certainly operated such that we would not fly any forced landing patterns, or one engine inoperative patterns if multi-engined, with passengers on board. Similarly, in later years low flying, and low level aerobatics/display flying (under civilian regulation), were not permitted with passengers on board.

This was such a tragic accident and however much Jon may have understood and accepted the risks it is his family and friends who will continue to be affected. This is the one aspect that must never be forgotten when considering the future.

[dervish]

Q1 - I think the risk posed to back-seat non-pilots on things like transit sorties is tolerable, hence why it continues. You will never remove all elements of risk.

The criteria is tolerable and ALARP, and so acknowledges all risk can never be removed. I think the point being made is that it obviously wasn't ALARP yet some 2* said it was. MoD have now accepted this.

[Thud105]

With regard to practice turnbacks (or indeed any simulated emergency), I remain unconvinced of the value of the exercise if the handling pilot instigates the situation. Be it an engine failure in a single engine airplane, chopping one throttle in a multi or simply pulling the cable release in a sailplane on a winch launch or aerotow, if the handling pilot closes the throttle/pulls the release etc then their mind is already in front of the situation. This is not the case in the real thing, which is why the instructor should always instigate the simulated emergency.

[dervish]

It is 4 years today since Corporal Bayliss was killed. RIP.

[biscuit74]

With regard to practice turnbacks (or indeed any simulated emergency), I remain unconvinced of the value of the exercise if the handling pilot instigates the situation. Be it an engine failure in a single engine airplane, chopping one throttle in a multi or simply pulling the cable release in a sailplane on a winch launch or aerotow, if the handling pilot closes the throttle/pulls the release etc then their mind is already in front of the situation. This is not the case in the real thing, which is why the instructor should always instigate the simulated emergency.


Entirely agree; there is a huge difference. (Which makes the accident behind this enquiry so puzzling; why not just throw it away early when you realise you have made it too hard for yourself? We all have bad days, poorer judgment days. Another reason for doing these exercises without unnecessary folk aboard.)

[Chugalug2]

Sean Cunningham's BoI stated that there was no Safety Case for the ejection seat he died in. That meant by extension that his aircraft was unairworthy. Thus all Hawks were also unairworthy then. Subsequently the T1's were to be grounded but the Reds' T1A's are to continue flying. Of course, the MOD avoids mention of the A word at all times, so is the Hawk still unairworthy? By the same token the Nimrod was officially airworthy until the MOD grounded them all and then said that it wasn't. I don't query that this fatal accident happened with the aircraft in an irrecoverable stall on short finals leading to the death of its rear seat passenger, but was it airworthy?

[SlopJockey]

Sean Cunningham's BoI stated that there was no Safety Case for the ejection seat he died in. That meant by extension that his aircraft was unairworthy. Thus all Hawks were also unairworthy then. Subsequently the T1's were to be grounded but the Reds' T1A's are to continue flying. Of course, the MOD avoids mention of the A word at all times, so is the Hawk still unairworthy? By the same token the Nimrod was officially airworthy until the MOD grounded them all and then said that it wasn't. I don't query that this fatal accident happened with the aircraft in an irrecoverable stall on short finals leading to the death of its rear seat passenger, but was it airworthy?

Airworthiness and Air Safety are not the same. Not having a safety case does not necessarily mean not airworthy.

Safe to Operate and Operated Safely are different questions.

It was not a technical failure that lead to loss of the aircraft.

Performing high risk manoeuvres with pax in the aircraft was prohibited for many activities such as LL flying, where the situation could degrade too rapidly for pax to observe, assimilate and act to a deteriorating situation.

The absence of command eject was a known issue and an aggravating factor.

Why was this activity allowed?

XX204 was not being operated safely.

[SlopJockey]

It is 4 years today since Corporal Bayliss was killed. RIP.
RIP Cpl Bayliss

[Chugalug2]

Airworthiness and Air Safety are not the same. Not having a safety case does not necessarily mean not airworthy.
So it was airworthy and had a safety case?
It was unairworthy and had no safety case?
It was airworthy but had no safety case?
It was unairworthy but had a safety case?
Which one please?

[Chugalug2]

David Hill has now published his latest book, A Noble Anger, which is available from your favourite South American bookseller in paperback at £5.99, or Kindle version at £2.49. It joins his other titles that relate to the sorry saga of the attack on airworthiness by RAF VSOs from which UK Military Aviation has never recovered, thanks to the continuing cover up of this scandal by the MOD. I would point out that A Noble Anger has been endorsed by Jon Bayliss's family and, as always, all net proceeds go to charity :-

https://www.amazon.co.uk/Noble-Anger-manslaughter-Corporal-Jonathan/dp/B0B6XLFY7Y/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=&sr=

A tip for those who are non-Prime customers, at Check-Out select a nearby Amazon Pick-Up location (lockers or shop) and delivery to there will be free, as this is an Amazon and not a Merchant sale

[dervish]

Thanks Chug

I bought the Kindle version and read it in one sitting. A well written in-depth investigation.

Not a harsh word about either the Reds or the pilot, the author spelling out why each were badly let down.

He identifies the failings that weren't mentioned in the RAF report. Among a series of revelations the biggest one is MoD lying to the court and family about previous occurrences. That meant the coroner ruled negligence but that it wasn't gross. I can't recall that being mentioned in the press.

The sub-title is 'The manslaughter of Jonathan Bayliss', which seems at first a bit presumptuous. But he sets out his case and by the end you're left thinking he might just be wrong. It's far worse.

A handbook for everyone involved in military aviation. £2.49 and proceeds to a worthy charity. BZ

[Lordflasheart]

...
I've just received one of those advertising emails suggesting, based on my previous readings, that I purchase a book entitled - "A Noble Anger: The manslaughter of Corporal Jonathan Bayliss."

Made it seem like an opportune moment to ask -

Is it true that North Wales Police are or have been investigating the Bayliss case from a manslaughter and/or 'lying to the Coroner' pov ?

LFH

[tucumseh]

...
I've just received one of those advertising emails suggesting, based on my previous readings, that I purchase a book entitled - "A Noble Anger: The manslaughter of Corporal Jonathan Bayliss."

Made it seem like an opportune moment to ask -

Is it true that North Wales Police are or have been investigating the Bayliss case from a manslaughter and/or 'lying to the Coroner' pov ?

LFH


Affirmative. Since just before Xmas 2022. Following a formal complaint by the family, and a retired Air Marshall coming forward to confirm that a senior officer's evidence under oath was 'wrong'. MoD denied this but the evidence, in the form of a DFS report, was produced by a well-known company. His 'wrong' evidence, it is suggested, made the difference between the Coroner's finding of negligence, and one of gross negligence.


They also asked that Lincs Police be involved given the 12 or so common factors between Bayliss and Cunningham, as MoD had assured the Lincs Coroner in 2014 that the recommendations were being implemented. You may recall that Lincs Police conducted an investigation in 2011/12, but later distanced themselves from it; and will not release any information on their work, nor even acknowledge any form of report was written. When asked to look at this, the Independent Police complaints people ruled that Lincs Police were correct to say that one is 'not entitled' to make a complaint, unless one is an affected party. They upheld this a further twice.

North Wales Police then disagreed with Lincs and the Complaints people, accepted the Bayliss family's complaint, and appointed a Detective Chief Inspector; whose progress seems rather slow, perhaps because of......

The Coroner's actions are included in the complaint, as she told the family only to ask questions, about the time of the accident, of said senior officer. When he took the stand, as the final witness, he announced he would NOT be answering these questions, and she allowed this. The Inquest closed about 2 minutes after her ruling, leaving the family nowhere to go.

Hope this helps. All in the public domain.