Mike Harland Inquest
Join Date: Apr 2007
Location: Away from home Rat
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
I have been waiting a long time to read that document.
They did a very through job and got most of the recommendations right too IMHO.. no.. with what I know of the place I used to work in before I left the service..
Thats all I'll say on the matter.
They did a very through job and got most of the recommendations right too IMHO.. no.. with what I know of the place I used to work in before I left the service..
Thats all I'll say on the matter.
Join Date: Apr 2007
Location: Away from home Rat
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
The inquest returned a verdict of "Accidental Death". It was the only real verdict that fitted as the one item that could have proved beyond doubt what happen was not found.
This incident has so many human factors input, it would make a good Air Clues article especially from the "I learned .. about that" perspective.
Some things in the BOI are not as accurate to the workings of CMU as they put it.. Work in CMU is not done on MOD Form 700 series or LITS generated documentation.. It is signed off on DMS and then some poor sod has to verify it and ensure that LITS (via LITS 707s) is updated.
DMS is the way BAE fulfil their MAOS 145 commitment. It isn't a LITS type maintenance ssytem as it was designed for manufacturing. In fact the acryomn means Direct Manufacturing System. All the tradesmen did as for conventional LITS data transfers on the shop floor (opposed to Squadron use) was asset exchanges. The rest was up to the docs guy to print the equipment labels and raise fault cards on the LITS system to indicate status changes. It took a few aircraft through the place to realise that no IPT visible fault reporting for the majority of unscheduled maintenance was occuring at all!
Armourer SNCOs got away lighty with their work recording. It was awful.
This incident has so many human factors input, it would make a good Air Clues article especially from the "I learned .. about that" perspective.
Some things in the BOI are not as accurate to the workings of CMU as they put it.. Work in CMU is not done on MOD Form 700 series or LITS generated documentation.. It is signed off on DMS and then some poor sod has to verify it and ensure that LITS (via LITS 707s) is updated.
DMS is the way BAE fulfil their MAOS 145 commitment. It isn't a LITS type maintenance ssytem as it was designed for manufacturing. In fact the acryomn means Direct Manufacturing System. All the tradesmen did as for conventional LITS data transfers on the shop floor (opposed to Squadron use) was asset exchanges. The rest was up to the docs guy to print the equipment labels and raise fault cards on the LITS system to indicate status changes. It took a few aircraft through the place to realise that no IPT visible fault reporting for the majority of unscheduled maintenance was occuring at all!
Armourer SNCOs got away lighty with their work recording. It was awful.
Join Date: Apr 2007
Location: Away from home Rat
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
It wasn't a patch on LITS Maintenance Manger for fault recording.. It was modified to track a maintenance schedule and a planner could add addition work to the schedule.. There was a faults (NRC) system in it as well (based on rework requirement originally I bet), but nothing was transferable electronically to the operator system (LITS) and if the workers didn't put the asset info on the DMS fault job number such as part numbers, transfering to the LITS fault database was impossible. The tracked items would be highlighted on DMS chits, so usually were not a problem.
A PART 145 MRO will use the operators scheduled taskcards and raise its own NRCs (that the operator will get copies of with all spares used). BAE Systems were allowed to draft their own schedule (true it was based on the relevent 5A1 and followed the logical trail), but visiblity of work was lost by its breakdown to the pulse system (No civvy MRO uses that!) and the paperless system of viewing what work was outstanding (again, no MRO works that way).
A PART 145 MRO will use the operators scheduled taskcards and raise its own NRCs (that the operator will get copies of with all spares used). BAE Systems were allowed to draft their own schedule (true it was based on the relevent 5A1 and followed the logical trail), but visiblity of work was lost by its breakdown to the pulse system (No civvy MRO uses that!) and the paperless system of viewing what work was outstanding (again, no MRO works that way).
Last edited by Alber Ratman; 22nd Oct 2010 at 20:05.
Join Date: Apr 2007
Location: Away from home Rat
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
The continued removal and fitting of seats using one main taskcard and with no fault documentation for the seats that were rejected.. All the LITS was done by the back door methods (were they should not have been). The BOI slates them (and the seat bay)for not doing things to the JAP. The BOI couldn't work out what work was done between the MMPs and LITS and they had a lot more time and resources than the poor sod in the docs cell who had to co-ordinate the thing. The MMPs were correctly signed for work content (bar that complete blocks were signed by one signature, that the BOI disargeed on as they believe individual sub blocks should be signed, but that is contentious for mps done by all trades). However the trimings (like completing each page to tie it to the work order etc and completion of the the front sheets) were not done, although at least the MMPs were co-ordinated by the people involved. The card returned contained about 20 MMPs and was almost the same size as all other LITS generated documentation for that maintenance.
As the BOI states in their recommendations, there were a few reviews required of the way CMU conducted their business in regards to CAMO reponsiblities for Tornado maintenance. They picked up faults with the F700 and short forecast. However it must be stated that the aircraft does not become LITS live untill the last DMS chit is checked and the DMS system is assured to have all work completed. It is only then that the last LITS MWO can be cleared and an accurate F721 can be printed. There was no F700 check done by an EngO, but RAF EngOs do not carry out that function in CMU anyway, a book audit is done by DQAFF staff. As stated, the short forecast was finally printed 4 minutes before the crew signed for the A/C. Why? because they were waiting in the office next to the desk where the book was finally being assembled! Things had gone wrong that morning when a nipped O ring seal was found on the A/F B/F. The whole post maintenance generation process was delayed, but BAE had to try and get that airtest carried out that day due to contractural arrangements with the MoD. The aircrew may not have been "presurising" but BAE managers were in the office, every half hour.
It was a horrible day.
As the BOI states in their recommendations, there were a few reviews required of the way CMU conducted their business in regards to CAMO reponsiblities for Tornado maintenance. They picked up faults with the F700 and short forecast. However it must be stated that the aircraft does not become LITS live untill the last DMS chit is checked and the DMS system is assured to have all work completed. It is only then that the last LITS MWO can be cleared and an accurate F721 can be printed. There was no F700 check done by an EngO, but RAF EngOs do not carry out that function in CMU anyway, a book audit is done by DQAFF staff. As stated, the short forecast was finally printed 4 minutes before the crew signed for the A/C. Why? because they were waiting in the office next to the desk where the book was finally being assembled! Things had gone wrong that morning when a nipped O ring seal was found on the A/F B/F. The whole post maintenance generation process was delayed, but BAE had to try and get that airtest carried out that day due to contractural arrangements with the MoD. The aircrew may not have been "presurising" but BAE managers were in the office, every half hour.
It was a horrible day.
The continued removal and fitting of seats using one main taskcard and with no fault documentation for the seats that were rejected.. All the LITS was done by the back door methods (were they should not have been). The BOI slates them (and the seat bay)for not doing things to the JAP. The BOI couldn't work out what work was done between the MMPs and LITS and they had a lot more time and resources than the poor sod in the docs cell who had to co-ordinate the thing. The MMPs were correctly signed for work content (bar that complete blocks were signed by one signature, that the BOI disargeed on as they believe individual sub blocks should be signed, but that is contentious for mps done by all trades). However the trimings (like completing each page to tie it to the work order etc and completion of the the front sheets) were not done, although at least the MMPs were co-ordinated by the people involved. The card returned contained about 20 MMPs and was almost the same size as all other LITS generated documentation for that maintenance.
Join Date: Apr 2007
Location: Away from home Rat
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
They were lucky that no service charges were raised for the paperwork issues. The seat remains held enough evidence to sugest what happen but training, proceedures and other factors (such as the TLP not being found) protected them from more serious charges (and rightly so).
Join Date: Apr 2007
Location: Away from home Rat
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
As the corenor stated at the summing up, there was a conflict of evidence between what the sciencific evidence from the remains of the seat and the aircraft portion of the system (such as the inner cylinder of the ejection gun had witness marks consistant with the TLP locking device being dragged across its surface) and RAF technicians (stating that the TLP was servicable and that the spring possibly have failed). The MMPs were clear on checks but training did not include ensuring the two point TLP checks were mandatory. Spring failure could not be discounted (because the mechanism was never found) but the witness marks to the BOI seem to suggest that the plunger spring pressure marks on the tube were consistant with it being intact (and the BOI did trials on other seats to confirm that). However no MB seat has ever fallen out on a military aircraft before this incident (examples of civilian owned seats have, due to incorrect fitting of the latch plunger). Without the TLP, proving a manslaughter charge beyond any reasonable doubt is impossible (and rightly so). Hard copy documents illustrating a neligence of duties in regards to airworthiness is also dodgy ground due to DMS and the way CMU interacted with the MAE. I'm not surprised the Provo's didn't pursue things on that score, but I reckon it was a closer thing than the more serious charges.
Join Date: Apr 2007
Location: Away from home Rat
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
And as the BOI stated, the lifting check was flawed. Trouble is a lot of armourers the world over took this to be the defining security check. Unfortunatley lifting the nose of the aircraft in this case was way below the actual forces that that seat was subjected to as the inverted manouver was applied with negative "G" thus doubling the actual weight of the seat/man combination.
The check has now been removed for all seat vital and indie proceedures, so I hear.
The check has now been removed for all seat vital and indie proceedures, so I hear.
Join Date: Dec 2003
Location: Lincolnshire
Posts: 477
Likes: 0
Received 0 Likes
on
0 Posts
Just to clarify -a MB seat exited a civilian JP in the 1990s but that was due to having leg restraint lines stowed beneath the seat stopping correct engagement of the latch . I am not aware of any other incidents of MB seats coming out of civilian operated aircraft .
Thread Starter
Join Date: Sep 2009
Location: Norfolk
Posts: 5
Likes: 0
Received 0 Likes
on
0 Posts
BBC report
Just to let you know my report on Mike H's inquest went on BBC Look East on Friday 22/10 ... tx at 1830 on BBC1.
A former GR1 navigator in Lancs who knew Mike from RAF days gave a great tribute, which sadly never made it into my film as the tape snapped in the play out machine.
Mike's widow and family showed immense courage and dignity at the inquest.
Piece can be seen at www.bbc.co/iplayer ... Search 'Look East' (only up until monday evening as next prog will be put on)
Thanks all for your background briefings and advice
Alex Dunlop
BBC East
A former GR1 navigator in Lancs who knew Mike from RAF days gave a great tribute, which sadly never made it into my film as the tape snapped in the play out machine.
Mike's widow and family showed immense courage and dignity at the inquest.
Piece can be seen at www.bbc.co/iplayer ... Search 'Look East' (only up until monday evening as next prog will be put on)
Thanks all for your background briefings and advice
Alex Dunlop
BBC East
Thread Starter
Join Date: Sep 2009
Location: Norfolk
Posts: 5
Likes: 0
Received 0 Likes
on
0 Posts
BBC iplayer
Apologies link to BBC iplayer did not have ...uk on end (typo) but having checked it, it looks like BBC is now updating weekend programmes, which means each programme only stays online for 24 hours....
Can only suggest u email [email protected] and ask for item to be put onto Internet. Enough requests will result in BBC putting it on BBC Norfolk website
Can only suggest u email [email protected] and ask for item to be put onto Internet. Enough requests will result in BBC putting it on BBC Norfolk website
Join Date: Apr 2007
Location: Away from home Rat
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
I lied about MB seats falling out of service aircraft. An incident occured to a USN A6 in 1991, pulling a neg G manouver.. Fortunately the seat failed to fully leave the aircraft and other circumstances saved the Nav in question. It wasn't the plunger that failed, but the latch window.
Linky
Linky