Flt. Lt. Sean Cunningham inquest
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Just to add
4th November 2011 was a Friday
8th November 2011 was a Tuesday
Just in case me and Mortmeister have made an assumption. I don't think the aircraft are left out overnight, let alone over the weekend.
Edit: In November, out of the display season
4th November 2011 was a Friday
8th November 2011 was a Tuesday
Just in case me and Mortmeister have made an assumption. I don't think the aircraft are left out overnight, let alone over the weekend.
Edit: In November, out of the display season
Thank you people for the explanation of the 1 1/2 thread matter ...... it seems extraordinary to a layman that something so vital should need judgement.
It was precisely to obviate "judgement" that the Met Office ceased using mercury barometers and went to precision aneroid versions: there was a number value to read, not a judgement to make.
On reading the value and logging it, the observer was required to calculate the difference from the previous reading as a first check, and see how the series was developing. Before passing the calculated various QFF QFE QNH values he was required to obtain the forecaster's initials. The forecaster kept a separate check board. On passing the values to ATC the observer was required to obtain ATC initials.
The aneroid itself was required to pass comparison checks with a travelling master instrument, which was itself recalibrated at Bracknell on a routine basis.
I offer the above as an illustration of how we went about safety by designing- out error to the nth degree.
It was precisely to obviate "judgement" that the Met Office ceased using mercury barometers and went to precision aneroid versions: there was a number value to read, not a judgement to make.
On reading the value and logging it, the observer was required to calculate the difference from the previous reading as a first check, and see how the series was developing. Before passing the calculated various QFF QFE QNH values he was required to obtain the forecaster's initials. The forecaster kept a separate check board. On passing the values to ATC the observer was required to obtain ATC initials.
The aneroid itself was required to pass comparison checks with a travelling master instrument, which was itself recalibrated at Bracknell on a routine basis.
I offer the above as an illustration of how we went about safety by designing- out error to the nth degree.
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Langley,
I think Mort sums up all the checks and balances that should have been in place at #180 quite nicely. just the same as your example of getting the altitude spot on. Air safety is a team effort and goes all the way back to the guy on the drawing board and everything in between. What we do need is total disclosure and honesty so we can all learn from each other and prevent the tragic occurrences like this.
I think Mort sums up all the checks and balances that should have been in place at #180 quite nicely. just the same as your example of getting the altitude spot on. Air safety is a team effort and goes all the way back to the guy on the drawing board and everything in between. What we do need is total disclosure and honesty so we can all learn from each other and prevent the tragic occurrences like this.
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The seat pins should have been moved to 'Safe for Maintenance' position and signed/countersigned by the armourers prior to being towed into the hangar after the previous flight. Although the Seat Pan Pin had been fitted by the pilot, the armourer concerned is required to check the correct fitment of that plus the MDC Firing Handle and the MDC Firing Unit Pins (all fitted by the pilot) in each cockpit.
4 days later when towed out, they should have been placed 'Safe for Parking,' again requiring a check of all pins as well as removing the Main Gun, Rocket Initiator and Manual Separation Firing Unit Pins. What happened during the time in the shed the BOI should know from aircraft paperwork.
4 days later when towed out, they should have been placed 'Safe for Parking,' again requiring a check of all pins as well as removing the Main Gun, Rocket Initiator and Manual Separation Firing Unit Pins. What happened during the time in the shed the BOI should know from aircraft paperwork.
The armourers didn't do them on AF/BF or turn rounds unless they to were operating as a Liney and as such would cover as one person would do, the whole jet. From checking the engines, airframe, electrics, NAVWASS, through to refuelling, oils and gasses such as seat oxy etc, the armourers simply rearmed / rerolled them and cleaned the guns or seat removal and fit.
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The seat pins should have been moved to 'Safe for Maintenance' position and signed/countersigned by the armourers prior to being towed into the hangar after the previous flight. Although the Seat Pan Pin had been fitted by the pilot, the armourer concerned is required to check the correct fitment of that plus the MDC Firing Handle and the MDC Firing Unit Pins (all fitted by the pilot) in each cockpit.
4 days later when towed out, they should have been placed 'Safe for Parking,' again requiring a check of all pins as well as removing the Main Gun, Rocket Initiator and Manual Separation Firing Unit Pins. What happened during the time in the shed the BOI should know from aircraft paperwork.
+++++++++++++++++++++++++++++++++++++++++++++++++
Was the earlier incorrect routing of strap through the seat handle and possible movement of the handle from its normal position formally recorded during post flight debrief as needing checking by armourer or seat specialist. Also is there any visible reference mark that makes it clear that the handle is correctly located. Can't understand why MB would design a handle where pin can be inserted when handle not fully seated.
4 days later when towed out, they should have been placed 'Safe for Parking,' again requiring a check of all pins as well as removing the Main Gun, Rocket Initiator and Manual Separation Firing Unit Pins. What happened during the time in the shed the BOI should know from aircraft paperwork.
+++++++++++++++++++++++++++++++++++++++++++++++++
Was the earlier incorrect routing of strap through the seat handle and possible movement of the handle from its normal position formally recorded during post flight debrief as needing checking by armourer or seat specialist. Also is there any visible reference mark that makes it clear that the handle is correctly located. Can't understand why MB would design a handle where pin can be inserted when handle not fully seated.
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To clarify for the benefit of Sirpeterhardingslovechild in post #177, if the handle is displaced from its housing with the seat pan pin out, the pin will not go back in the correct hole. End of.
Assuming the handle was only 'soft pulled' to the first detent and hadn't fired, which has happened several times between three types I've flown in my career, it can be re-seated, not without losing a few heartbeats, and the pin reseated correctly. Drama over. Rare but documented.
However, this small displacement opens a gap between the handle base and its housing which the pin can be (and has been) pushed into. In this case, the handle is still at the first detent, cannot be reseated and is liable to fire the seat with a further upward pull of sufficient force.
If the seat occupant was to relocate the pin, by feel into the gap they would be none the wiser. The error could only be seen by adjusting the QRF/paunch/fat thighs and looking vertically down to check the pin was centrally located in the handle. I always checked by sight before unstrapping, particularly after seeing pictures, pre-dating the incident in question.
Anyone looking in or down, checking that the pin is fitted, particularly with parallax from peering into the cockpit, could see the pin's handle and assume that it was safe if they didn't look to see that the handle was housed and the pin CENTRALLY LOCATED AND FULLY HOME.
I hope this clarifies for those who have a little bit of (dangerous) knowledge. I find the level of amateur speculation here appalling. This incident was close to me on several fronts.
Ray.
Assuming the handle was only 'soft pulled' to the first detent and hadn't fired, which has happened several times between three types I've flown in my career, it can be re-seated, not without losing a few heartbeats, and the pin reseated correctly. Drama over. Rare but documented.
However, this small displacement opens a gap between the handle base and its housing which the pin can be (and has been) pushed into. In this case, the handle is still at the first detent, cannot be reseated and is liable to fire the seat with a further upward pull of sufficient force.
If the seat occupant was to relocate the pin, by feel into the gap they would be none the wiser. The error could only be seen by adjusting the QRF/paunch/fat thighs and looking vertically down to check the pin was centrally located in the handle. I always checked by sight before unstrapping, particularly after seeing pictures, pre-dating the incident in question.
Anyone looking in or down, checking that the pin is fitted, particularly with parallax from peering into the cockpit, could see the pin's handle and assume that it was safe if they didn't look to see that the handle was housed and the pin CENTRALLY LOCATED AND FULLY HOME.
I hope this clarifies for those who have a little bit of (dangerous) knowledge. I find the level of amateur speculation here appalling. This incident was close to me on several fronts.
Ray.
Interesting...
Which 'correct hole'? The correct hole in the handle, or the correct hole in the collar around the handle?
I think all you did was muddy the water there with a bit of speculation. Sean's pin was in the correct hole on the handle, not in a gap between handle and seat. However because the handle had been pulled upwards the hole in the handle was above the level of the collar so there was nothing preventing the final pull.
To clarify for the benefit of Sirpeterhardingslovechild in post #177, if the handle is displaced from its housing with the seat pan pin out, the pin will not go back in the correct hole. End of.
I hope this clarifies for those who have a little bit of (dangerous) knowledge. I find the level of amateur speculation here appalling.
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which is a design fault - if the handle is not fully home there should be zero way for the pin to be fitted back into the correct hole.
and I still dont buy the bit about being able to "not notice" you have routed a big black and yellow scary handle thru the straps.
if it is possible then lets see pics on a deactivated trg seat or one with the carts removed to demonstrate how this is all Flt Lt Cunningham's fault.
WHICH I DO NOT BELIEVE FOR ONE SECOND.
there is far more to this than a simple chain of operator errors.
and I still dont buy the bit about being able to "not notice" you have routed a big black and yellow scary handle thru the straps.
if it is possible then lets see pics on a deactivated trg seat or one with the carts removed to demonstrate how this is all Flt Lt Cunningham's fault.
WHICH I DO NOT BELIEVE FOR ONE SECOND.
there is far more to this than a simple chain of operator errors.
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Ref post 186...
Assuming the handle was only 'soft pulled' to the first detent and hadn't fired, which has happened several times between three types I've flown in my career, it can be re-seated, not without losing a few heartbeats, and the pin reseated correctly. Drama over. Rare but documented.
Just for clarification, I assume the seat would have to be thoroughly checked by the relevant specialists first after being 'Soft pulled', so not just the 'Drama over' as it came across to me.
I probably mistook your meaning, but a pilot, or any other 'Non seat specialist' re-seating a moved handle would be mad in my opinion.
Engineers are curious people & do think 'Cross trade' it's in our nature, just asking questions, not really giving opinions.
Assuming the handle was only 'soft pulled' to the first detent and hadn't fired, which has happened several times between three types I've flown in my career, it can be re-seated, not without losing a few heartbeats, and the pin reseated correctly. Drama over. Rare but documented.
Just for clarification, I assume the seat would have to be thoroughly checked by the relevant specialists first after being 'Soft pulled', so not just the 'Drama over' as it came across to me.
I probably mistook your meaning, but a pilot, or any other 'Non seat specialist' re-seating a moved handle would be mad in my opinion.
Engineers are curious people & do think 'Cross trade' it's in our nature, just asking questions, not really giving opinions.
to demonstrate how this is all Flt Lt Cunningham's fault.
WHICH I DO NOT BELIEVE FOR ONE SECOND.
WHICH I DO NOT BELIEVE FOR ONE SECOND.
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so the insinuation it is all the fault of the pilot strapping in incorrectly twice is the root cause has passed you by?
now if I remember correctly and it is o' stupid o clock and i need coffee so i stand proud to be corrected by any plumbers, the handle pulls on a trapezium type shaped release that when fully removed allows the spring inside to expand forcing the firing pin into the cart starting off the process.
said handle requires a fairly hefty chunk of force 30-40lb, IIRC, to pull.
Now, you try picking up a strap, feeding it thru a black and yellow handle and connecting it up as per my previous post AND THEN TIGHTENING THE STRAPS TO PUT 30-40lb of into the handle to move it even to the first detent. ( something I don't recall)
it does not matter which strap, the crotch, the lap, the neg G and QRF or the shoulder.
it does not strike me as unnoticable - now, those of you fortunate enough to have had a seat incident and be here to recount it, when you realised you might have made a cock up and needed the assistance of an armourer can i assume that you made damn sure you went nowhere near the handle or did anything to upset a mechanism while waiting and saying a lot of prayers?
let us say, for example you realised the handle was part pulled - for whatever reason......
what are you going to do...?
now onto this other bit - the part about the handle being part pulled and the pin put back incorrectly, park the bit that it won't go thru the hole as it does not line up and so therefore must be put between the handle base and the top of the housing???
yeah, i'm having trouble buying this too and then a chain of 19 (as reported) people all fail to notice the pin does not look right.
Are they ALL so blase about seat safety that they cannot see a pin is not in the correct place.
19 separate entries into that cockpit, plus the entry of Flt Lt Cunningham on that sad day........?
ALL missed it....
I dont think so.
now if I remember correctly and it is o' stupid o clock and i need coffee so i stand proud to be corrected by any plumbers, the handle pulls on a trapezium type shaped release that when fully removed allows the spring inside to expand forcing the firing pin into the cart starting off the process.
said handle requires a fairly hefty chunk of force 30-40lb, IIRC, to pull.
Now, you try picking up a strap, feeding it thru a black and yellow handle and connecting it up as per my previous post AND THEN TIGHTENING THE STRAPS TO PUT 30-40lb of into the handle to move it even to the first detent. ( something I don't recall)
it does not matter which strap, the crotch, the lap, the neg G and QRF or the shoulder.
it does not strike me as unnoticable - now, those of you fortunate enough to have had a seat incident and be here to recount it, when you realised you might have made a cock up and needed the assistance of an armourer can i assume that you made damn sure you went nowhere near the handle or did anything to upset a mechanism while waiting and saying a lot of prayers?
let us say, for example you realised the handle was part pulled - for whatever reason......
what are you going to do...?
now onto this other bit - the part about the handle being part pulled and the pin put back incorrectly, park the bit that it won't go thru the hole as it does not line up and so therefore must be put between the handle base and the top of the housing???
yeah, i'm having trouble buying this too and then a chain of 19 (as reported) people all fail to notice the pin does not look right.
Are they ALL so blase about seat safety that they cannot see a pin is not in the correct place.
19 separate entries into that cockpit, plus the entry of Flt Lt Cunningham on that sad day........?
ALL missed it....
I dont think so.
I think its disgusting that these insinuations are made in court. Is it an MoD thing, or an RAF thing? Seems to me it happens at almost every RAF inquest and seldom at others. If it turns out the Board of Inquiry had already determined the pilot was not to blame, then whoever made these insinuations should be put in a hole.
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I think its disgusting that these insinuations are made in court. Is it an MoD thing, or an RAF thing? Seems to me it happens at almost every RAF inquest and seldom at others. If it turns out the Board of Inquiry had already determined the pilot was not to blame, then whoever made these insinuations should be put in a hole.
I would counter with:
- The Mull Chinook accident showed that MoD BoI/SI system is not necessarily the whole story
- An Aircraft Accident investigation is generally to learn from / prevent future occurrences, and not to allocate blame.
- I do not know exactly the (defined) purpose of an inquest, but I am pretty sure it is not as the item above.
Meanwhile, I think to those on the outside, we are just seeing a complex legal process occurring with conflicting information / apparent purpose confusing to the layman.
NoD
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raytofclimb
To clarify for the benefit of Sirpeterhardingslovechild in post #177, if the handle is displaced from its housing with the seat pan pin out, the pin will not go back in the correct hole. End of.
I hope this clarifies for those who have a little bit of (dangerous) knowledge. I find the level of amateur speculation here appalling. This incident was close to me on several fronts.
cornish-stormrider
to demonstrate how this is all Flt Lt Cunningham's fault.
WHICH I DO NOT BELIEVE FOR ONE SECOND.
Don't think anyone said "all Flt Lt Cunningham's fault"
If any of those comments are directed at me, I'm happy to stick my neck out and state that he was at least partly responsible.
Possibly, further down the line, lawyers will put a percentage on this and its called "contributory negligence"
To clarify for the benefit of Sirpeterhardingslovechild in post #177, if the handle is displaced from its housing with the seat pan pin out, the pin will not go back in the correct hole. End of.
I hope this clarifies for those who have a little bit of (dangerous) knowledge. I find the level of amateur speculation here appalling. This incident was close to me on several fronts.
cornish-stormrider
to demonstrate how this is all Flt Lt Cunningham's fault.
WHICH I DO NOT BELIEVE FOR ONE SECOND.
Don't think anyone said "all Flt Lt Cunningham's fault"
If any of those comments are directed at me, I'm happy to stick my neck out and state that he was at least partly responsible.
Possibly, further down the line, lawyers will put a percentage on this and its called "contributory negligence"
Now, you try picking up a strap, feeding it thru a black and yellow handle and connecting it up as per my previous post AND THEN TIGHTENING THE STRAPS TO PUT 30-40lb of into the handle to move it even to the first detent.
Feeding into such an occurrence could be groundcrew dilution (ie why didn't the liney spot the strap error?), unit culture/SOPs (were they imposing unnecessary time pressure?), safety process (awareness of previous close calls) and seat design issues. The practice of unstrapping during taxy back (during which the pilot tends not to look down, replacing the pin and undoing straps by feel) would also remove the opportunity for others to spot the condition.
so the insinuation it is all the fault of the pilot strapping in incorrectly twice is the root cause has passed you by?
Last edited by Easy Street; 26th Jan 2014 at 10:23.
Nigel, you quoted my post but then listed points as if I'd argued against them.
The Inquest (in England) is meant to be non-adverserial but MoD (RAF) always seem keen to introduce unfounded accusations to divert attention from the main issues and are very good at persuading inquiries that certain witnesses shouldn't be called or facts revealed. Just an observation based on fact, including the Mull of Kintyre accident you mentioned.
The Inquest (in England) is meant to be non-adverserial but MoD (RAF) always seem keen to introduce unfounded accusations to divert attention from the main issues and are very good at persuading inquiries that certain witnesses shouldn't be called or facts revealed. Just an observation based on fact, including the Mull of Kintyre accident you mentioned.
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Purpose of inquest?
Nigel,
I believe that the purpose of an inquest is solely to determine the cause of a death. In Scotland the rather more descriptive "fatal accident enquiry" fills the same role.
There may be a secondary opportunity to advise on lessons for the future and to spot trends to similar incidents in the past, but that's not the prime concern. I'd say an inquest is much closer in goals to a board of inquiry/accident investigation than to a trial, but the inquest is more narrowly focussed on the death, rather than building up a whole picture of an accident.
There's a lot of flexibility in the approach the coroner takes to consider wider issues. In a complex case like this, the coroner will be seeking to decide whether there is sufficient evidence to rule it was an "unlawful killing" or an "accident", or if the cause remains "open".
If it's "unlawful killing", then some sort of police investigation would be expected. It's also possible for an inquest to come to different conclusions from an inquiry, perhaps consistently, because of its different emphasis.
I believe that the purpose of an inquest is solely to determine the cause of a death. In Scotland the rather more descriptive "fatal accident enquiry" fills the same role.
There may be a secondary opportunity to advise on lessons for the future and to spot trends to similar incidents in the past, but that's not the prime concern. I'd say an inquest is much closer in goals to a board of inquiry/accident investigation than to a trial, but the inquest is more narrowly focussed on the death, rather than building up a whole picture of an accident.
There's a lot of flexibility in the approach the coroner takes to consider wider issues. In a complex case like this, the coroner will be seeking to decide whether there is sufficient evidence to rule it was an "unlawful killing" or an "accident", or if the cause remains "open".
If it's "unlawful killing", then some sort of police investigation would be expected. It's also possible for an inquest to come to different conclusions from an inquiry, perhaps consistently, because of its different emphasis.
It's also possible for an inquest to come to different conclusions from an inquiry, perhaps consistently, because of its different emphasis
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I have a query regarding the seats in general as I'm not technically minded regarding such matters.
If the seats are fitted with five safety pins and the one in the seat pan was incorrectly fitted, regardless of how, why did the other pins insertion not stop the firing sequence? Is not the removal of the pins the last sequence before engine start as another safety check?
I always thought the idea of the pins was like a weapons safety catch in simple terms in equals no go, out means go out.
If the seats are fitted with five safety pins and the one in the seat pan was incorrectly fitted, regardless of how, why did the other pins insertion not stop the firing sequence? Is not the removal of the pins the last sequence before engine start as another safety check?
I always thought the idea of the pins was like a weapons safety catch in simple terms in equals no go, out means go out.
Just to clear up a couple of points.
It is very possible to fit the seat pan pin into the seat housing with the handle displaced,this has happened before on a different aircraft type within the last 12 years.
As others have said - straps / neg g straps have been wrongly routed within the last 5 years on hawk aircraft during strap in !
Finally to help deflect the conspiracy theory - I would just like to say that except for during seat maintenance (ie deeper than line maintenance) the ONLY person who touches the seat pan pin is the pilot/aircrew occupying the seat...NOBODY else would dare touch the pin - it is absolutely drilled into all groundcrew that we do not touch the seat pan pin...and there is absolutely no need for us to touch that pin !
Also to say that at some units - if the aircraft is serviceable and will be flying
the next day or pretty soon - the seat pins are not moved from pins park to pins serv/maint !I am not saying that the reds do this but some units do !
It is very possible to fit the seat pan pin into the seat housing with the handle displaced,this has happened before on a different aircraft type within the last 12 years.
As others have said - straps / neg g straps have been wrongly routed within the last 5 years on hawk aircraft during strap in !
Finally to help deflect the conspiracy theory - I would just like to say that except for during seat maintenance (ie deeper than line maintenance) the ONLY person who touches the seat pan pin is the pilot/aircrew occupying the seat...NOBODY else would dare touch the pin - it is absolutely drilled into all groundcrew that we do not touch the seat pan pin...and there is absolutely no need for us to touch that pin !
Also to say that at some units - if the aircraft is serviceable and will be flying
the next day or pretty soon - the seat pins are not moved from pins park to pins serv/maint !I am not saying that the reds do this but some units do !