Flt. Lt. Sean Cunningham inquest
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One_of_the_Strange over on ARRSE brought up a good point regarding the 'illogical' faliure to inform MoD:
Well, I worked for them in the 90's and based on that I wonder whether or not the coroner was aware of the seismic changes that occurred around then in the way the UK handled such things. Back in the day (pre Eurofighter) qualification and acceptance of seats for the UK forces was done by Bedford and Boscombe Down using their aircraft, facilities and staff. That would certainly have been the case for the original 10B Hawk seat. There was also a high degree of involvement by the Institute of Aviation Medicine in many of the details. So MBA would never have been involved in signing things off and would have not have dealt directly with the user.
Arrangements differed for export customers, depending on exactly what they wanted to pay MBA for and what they wanted to do themselves. But again in the back of my mind I have the feeling that export users would be far more likely to be sent stuff directly from MBA as they were quite happy to have MBA qual the seat for them and handle all technical issues.
So, all that was fine and dandy as long as it lasted. But then Bedford closed, Boscombe shrank to a shadow of it's former self and (when I dealt with them) their fleet of three test aircraft and tens of staff had shrunk to half a graduate and some filing cabinets. Which I pillaged one day as part of some work we were doing for the MoD to find that only a rather sparse set of documentation remained. I think it was the first time we'd seen any of it, and we were doing the work as the MoD was no longer able to do anything like it any more. Oh, and the Institute of AM had become a School and the decades of experience they used to have had walked.
Then of course we have the slow death of airworthiness in the MoD as detailed in the Haddon-Cave report. Past my time of course, but not an environment conducive to the painstaking attention to detail needed to catch this sort of problem.
Now, MBA certainly had (maybe they still do ?) a reputation in some quarters as a bolshy bunch of bastards to work with but that bolshiness consisted of telling various customers and airframers that they were talking nonsense and would they kindly shut up and listen to someone who understood the problem. They still exist as a company because they get things right, and Air Forces tend to be run by people who look favourably on that attitude towards escape systems.
So I firmly believe that if MBA knew there was a problem in service they'd have made noises, and lots of them. However, if they'd sent the paperwork to an organisation in turmoil and it got binned, fell between the cracks I wouldn't be surprised at all. Maybe they just assumed that the system would work as it always had done without realising that it wasn't any more.
Arrangements differed for export customers, depending on exactly what they wanted to pay MBA for and what they wanted to do themselves. But again in the back of my mind I have the feeling that export users would be far more likely to be sent stuff directly from MBA as they were quite happy to have MBA qual the seat for them and handle all technical issues.
So, all that was fine and dandy as long as it lasted. But then Bedford closed, Boscombe shrank to a shadow of it's former self and (when I dealt with them) their fleet of three test aircraft and tens of staff had shrunk to half a graduate and some filing cabinets. Which I pillaged one day as part of some work we were doing for the MoD to find that only a rather sparse set of documentation remained. I think it was the first time we'd seen any of it, and we were doing the work as the MoD was no longer able to do anything like it any more. Oh, and the Institute of AM had become a School and the decades of experience they used to have had walked.
Then of course we have the slow death of airworthiness in the MoD as detailed in the Haddon-Cave report. Past my time of course, but not an environment conducive to the painstaking attention to detail needed to catch this sort of problem.
Now, MBA certainly had (maybe they still do ?) a reputation in some quarters as a bolshy bunch of bastards to work with but that bolshiness consisted of telling various customers and airframers that they were talking nonsense and would they kindly shut up and listen to someone who understood the problem. They still exist as a company because they get things right, and Air Forces tend to be run by people who look favourably on that attitude towards escape systems.
So I firmly believe that if MBA knew there was a problem in service they'd have made noises, and lots of them. However, if they'd sent the paperwork to an organisation in turmoil and it got binned, fell between the cracks I wouldn't be surprised at all. Maybe they just assumed that the system would work as it always had done without realising that it wasn't any more.
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Has it been confirmed that MB omitted to tell the RAF altogether or could it have been a case of the information going to the wrong place and getting ignored as in "send three and four pence, we are going to a dance".
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Yep, which I wondered earlier, it wouldn't surprise me in the least if the signals / faxes / emails were being sent to dead addresses, or they were simply missed of the mailing list.
The pilot was strapped in. He can do that himself if away from base by himself, but it was at Scampton so his mechanic would have helped him with the shoulder straps and anything else he requested
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emails were being sent to dead addresses, or they were simply missed of the mailing list.
would not an acknowledgment of receipt be required?
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@ Alber Ratman... Please could you re arrange the words in your last post, "into a well known phrase or saying" 
@ A W Blain, re-post 201....I attended an inquest on Dec. 5 th. The Coroner informed that they no longer issue a "verdict" but a "conclusion"
Where there is not a single, definitive cause of death, he files a Narrative Conclusion.......The Death Certificate has only just been issued, so I don't yet know the format.
As you said, Coroner can make recommendations,but their job is to ascertain cause of death, not to apportion blame.....but in the course of disseminating the information that led to his conclusion, the finger can point clearly!
Edit: A.R's post has been deleted.
@ A W Blain, re-post 201....I attended an inquest on Dec. 5 th. The Coroner informed that they no longer issue a "verdict" but a "conclusion"
Where there is not a single, definitive cause of death, he files a Narrative Conclusion.......The Death Certificate has only just been issued, so I don't yet know the format.
As you said, Coroner can make recommendations,but their job is to ascertain cause of death, not to apportion blame.....but in the course of disseminating the information that led to his conclusion, the finger can point clearly!
Edit: A.R's post has been deleted.
Last edited by cockney steve; 30th Jan 2014 at 09:35.
when this era of aircraft were designed and the manuals written the system was completely different. They were maintained by fully skilled people. The manuals didnt specify every task the way they do now. I was in KSA for the start of Hawk ops using the old USAF trade system. The manuals didnt comply so we were forever raising amendments to Bae , Tornado was similar.
Also, "raising amendments" (actually, requesting that ATP progress amendments via the PDS contract, with the parallel task of updating the safety case) does not actually guarantee anything will be done, as the funding was slashed in 91/92, and then removed for a long period altogether in 93. The work that the Chief Engineer ruled should not be funded was not retrospectively carried out, which means gaps exist. The relevant procedural Def Stan (another example of something that assumed a level of training) has long been cancelled, without replacement.
The SI report recommends - training courses.
Training courses are FAU if the personnel system permits "managers" to skip their first 5 grades, and not require them to catch up on all that training and experience they've missed.
Seat Firing
I may well have missed it despite careful perusal of all the posts, but what DID initiate the seat firing ? I have not yet seen the SI report.
I can understand that a jammed shackle could have caused failure of the chute to deploy (but for the life of me I can't understand ANY armourer working on the seat NOT ensuring freedom of operation.)
The seat pin may have been incorrectly inserted but that doesn't mean the seat will fire unless a very significant pull is applied to the firing handle. (although having done it in anger on a Mk 4 seat, the pull force pales into insignificance when adrenalin kicks in )
I understand that NO straps were found routed via the handle so just what DID cause seat firing ?
Is the answer known or is it just (informed) speculation?
I can understand that a jammed shackle could have caused failure of the chute to deploy (but for the life of me I can't understand ANY armourer working on the seat NOT ensuring freedom of operation.)
The seat pin may have been incorrectly inserted but that doesn't mean the seat will fire unless a very significant pull is applied to the firing handle. (although having done it in anger on a Mk 4 seat, the pull force pales into insignificance when adrenalin kicks in )
I understand that NO straps were found routed via the handle so just what DID cause seat firing ?
Is the answer known or is it just (informed) speculation?
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Neither do some of the posters on this thread - it's not just the press.
DV
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RE- TUCUMSEH's post above...
Any "training system" that is not fully documented, is fundamentally flawed. Especially-so in a Military where it is a given that the grunts on the ground will have a relatively short carreer span......so what a bloody brilliant idea, hey, -let's go back to the industrial revolution, nothing written down, all knowledge passed by word of mouth.....for those a bit lacking in History, Caxton's printing press opened-up the "Craftsman's Clubs" once the peasants could read, they could learn skills easily and cheaply. (Mastering them, was another issue.......
here we were , in the 20 th. century, relying on an instructor's memory to tell a new load of "oiks" everything . The half-baked "constant amendment and update" protocol that TUC. referred to, was fatally flawed.
the comprehensive "Old-School" knowledge was pushed out of the door by MOD bean-counters.
Their chickens have come home to roost.
A proper service and maintenance manual should detail exactly what maintenance and repair operations should be carried out, when, and most importantly how
As kit becomes obsolete, new manuals and procedures are needed, It's a continuous , evolving process.
From what I've read here, seems the MOD cut off any proper support to the fixers...perhaps they thought the odd death , like Mr. Cunningham's , would be cheaper.
I do hope the Coroner has the initiative to look behind the MOD's shameful curtain .
Any "training system" that is not fully documented, is fundamentally flawed. Especially-so in a Military where it is a given that the grunts on the ground will have a relatively short carreer span......so what a bloody brilliant idea, hey, -let's go back to the industrial revolution, nothing written down, all knowledge passed by word of mouth.....for those a bit lacking in History, Caxton's printing press opened-up the "Craftsman's Clubs" once the peasants could read, they could learn skills easily and cheaply. (Mastering them, was another issue.......
here we were , in the 20 th. century, relying on an instructor's memory to tell a new load of "oiks" everything . The half-baked "constant amendment and update" protocol that TUC. referred to, was fatally flawed.
the comprehensive "Old-School" knowledge was pushed out of the door by MOD bean-counters.
Their chickens have come home to roost.
A proper service and maintenance manual should detail exactly what maintenance and repair operations should be carried out, when, and most importantly how
As kit becomes obsolete, new manuals and procedures are needed, It's a continuous , evolving process.
From what I've read here, seems the MOD cut off any proper support to the fixers...perhaps they thought the odd death , like Mr. Cunningham's , would be cheaper.
I do hope the Coroner has the initiative to look behind the MOD's shameful curtain .
cockney steve
Thank you. You are absolutely right.
Could I just clarify that the "bean counters" who chopped the funding (i.e. made savings at the expense of safety) are well known and were named in evidence to both Haddon-Cave and Lord Philip; evidence made irrefutable because it included their directives from June 1987 to June 1993. Almost to a man they were Air Rank officers. Even MoD have now chosen not to challenge this historical fact.
I predict, like the Nimrod and Chinook Reviews, the recommendations will be replaceable with "Implement mandated policy".
Thank you. You are absolutely right.
Could I just clarify that the "bean counters" who chopped the funding (i.e. made savings at the expense of safety) are well known and were named in evidence to both Haddon-Cave and Lord Philip; evidence made irrefutable because it included their directives from June 1987 to June 1993. Almost to a man they were Air Rank officers. Even MoD have now chosen not to challenge this historical fact.
I predict, like the Nimrod and Chinook Reviews, the recommendations will be replaceable with "Implement mandated policy".
CS:_
Only for the victims I'm afraid. Those who initiated and perpetuated the sabotage of UK Military Air Safety remain unscathed, their reputations unsullied. In stark contrast the families and loved ones of those who perished in Airworthiness Related Fatal Military Air Accidents have a lifetime sentence of grief imposed upon them.
The pity of it is that there appears to be no institution or organisation in the land that is professional enough, powerful enough, or cares enough to challenge the lies and obfuscations of the MOD and the Star Chamber (both serving and retired).
One yearns for such a professional body to bring them to account, to highlight the illegal orders and the suborning of the Regulations that resulted. In short one yearns for a truly independent Military Airworthiness Authority and a Military Air Accident Investigator, when all we have are the MAA and the MAAIB. Unless and until they are made independent of the MOD and of each other, we must depend on an 800 year old institution to tell one that is less than 100 years old, "There is something wrong with your bloody aircraft!".
Their chickens have come home to roost.
The pity of it is that there appears to be no institution or organisation in the land that is professional enough, powerful enough, or cares enough to challenge the lies and obfuscations of the MOD and the Star Chamber (both serving and retired).
One yearns for such a professional body to bring them to account, to highlight the illegal orders and the suborning of the Regulations that resulted. In short one yearns for a truly independent Military Airworthiness Authority and a Military Air Accident Investigator, when all we have are the MAA and the MAAIB. Unless and until they are made independent of the MOD and of each other, we must depend on an 800 year old institution to tell one that is less than 100 years old, "There is something wrong with your bloody aircraft!".
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A proper service and maintenance manual should detail exactly what maintenance and repair operations should be carried out, when, and most importantly how
INSTALLATION.
Before installing the engine on the aircraft, install any items which were
removed from the engine or aircraft after the engine was removed
removed from the engine or aircraft after the engine was removed
Fine if you actually took it out and the muppet prior to you didn't just write engine removed, accessories removed, engine sent for overhaul. ...
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Recording a narrative verdict, Coroner Stuart Fisher said the safety pin mechanism was "entirely useless" and said the pin's presence was "likely to mislead".
Is anyone else in PPRuNe-land uncomfortable with this? "Flawed" and "possible to mislead" would be a more responsible thing to say (from a respected 800 year old institution)
This leads to Flt Lt Cunningham's Dad saying
"We welcome the conclusion of the coroner which confirmed what we knew all along, which is that Sean was blameless and his tragic death was preventable"
With the greatest of respect, sir. By any measure, and on at least 2 key points, Sean shares some of the blame.
It is a very serious matter to blame the MoD & MB, when it is clear that complacency, and plain bad luck had a large part to play here. MB statistics alone point to this.
I've got this 'orrible feeling I'm taking the attitude of the Mull of Kintyre Airships here. But I see that the family accepted a settlement in Dec '13 so this one in done & dusted...waiting for the BoI report
Is anyone else in PPRuNe-land uncomfortable with this? "Flawed" and "possible to mislead" would be a more responsible thing to say (from a respected 800 year old institution)
This leads to Flt Lt Cunningham's Dad saying
"We welcome the conclusion of the coroner which confirmed what we knew all along, which is that Sean was blameless and his tragic death was preventable"
With the greatest of respect, sir. By any measure, and on at least 2 key points, Sean shares some of the blame.
It is a very serious matter to blame the MoD & MB, when it is clear that complacency, and plain bad luck had a large part to play here. MB statistics alone point to this.
I've got this 'orrible feeling I'm taking the attitude of the Mull of Kintyre Airships here. But I see that the family accepted a settlement in Dec '13 so this one in done & dusted...waiting for the BoI report
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I assume that the SI report will confirm that on examining the seat after firing,
(1) The seat safety pin was still in the hole but not engaging the firing handle.
(2) The "nut and bolt" displayed more than one and half thread turns, which was consistant with over tighening.
(3) The date of the last servicing and the publication used.
DV
(1) The seat safety pin was still in the hole but not engaging the firing handle.
(2) The "nut and bolt" displayed more than one and half thread turns, which was consistant with over tighening.
(3) The date of the last servicing and the publication used.
DV
SPHL:-
The bad luck seems to have been that this aircraft had an escape system that was "entirely useless". Other than something on which a pilot could park his backside the rest of it was so much dead weight, and as it turned out very dangerous deadweight at that. Because of that the aircraft was as unairworthy as the Mull Chinook, the Iraq Tornado, the Afghanistan Nimrod, etc. There is the same common thread linking those tragedies with this one, ie a dysfunctional UK military airworthiness provision system.
As you say, let us see if the SI Report reveals that, and if so why that was. Or not...
A new MOD tactic to settle before both inquest and SI publication? Now why would they do that I wonder?
and plain bad luck had a large part to play here.
As you say, let us see if the SI Report reveals that, and if so why that was. Or not...
the family accepted a settlement in Dec '13 so this one in done & dusted
I can't be the only ex- or current Hawk pilot who thinks that branding the entire escape system "entirely useless" simply isn't true. It's saved a few of my friends!
You could put the pin somewhere if the handle was half-pulled. You could also miss the hole and jam it in by the side of the handle. That's why we were always taught, even as Hawk students, to physically check it, and look to make sure it was correctly located.
The system was flawed in the sense that you could put the pin somewhere that didn't make the seat safe. That doesn't mean the whole system was suddenly "entirely useless."
You could put the pin somewhere if the handle was half-pulled. You could also miss the hole and jam it in by the side of the handle. That's why we were always taught, even as Hawk students, to physically check it, and look to make sure it was correctly located.
The system was flawed in the sense that you could put the pin somewhere that didn't make the seat safe. That doesn't mean the whole system was suddenly "entirely useless."