Flt. Lt. Sean Cunningham inquest
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Background I know the one in the headrest that was mentioned, but I'm sure the one I was thinking of was a sidebar outboard of the headrest.
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I also repeat the question. Were ANY OTHER BOLTS FOUND PINCHING THE SHACKLE during the fleet checks or was this one the only example ?
This guy was seriously unlucky.
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It's my understanding that previous ejections (involving this Mk of ejection seat)had only succeeded because they were not zero zero ejections, and that MB were allegedly aware of this.
All rumour of course.
All rumour of course.
I also repeat the question. Were ANY OTHER BOLTS FOUND PINCHING THE SHACKLE during the fleet checks or was this one the only example ?
Excellent question, but worth pointing out a related MoD policy (Adam Ingram, when Min(AF), and successors) that a trend failure can now only exist in the tail number in question. That is, it may be considered a trend if it occurs more than once in a tail number, but not if it occurs once in every aircraft in the fleet.
Interesting concept, which explains much, with roots in the Chief Engineer policy of 1991 to cease all fault monitoring tasks. That recurring date again.
To be fair to the MAA, they haven't said they agree with this; but neither have they disagreed and continue to support the DE&S authors of the Ministerial brief. (Your balls hurt if you sit on the fence too long).
I disagree by the way.
The main point here is that the fleet inspection occurred after the accident, yet the problem was known beforehand. Exactly the same happened prior to Tornado ZG710/patriot shootdown (2003) - 2 dead - so lessons aren't being learned. Don't be blinded by any MoD spin that no other faults were found. The death was avoidable and MoD policy militated against avoidance.
SI report this week?
The Service Inquiry report will be released on 6 Feb
In answer to a question about redaction, they have also said (my bold)
It is MOD policy to redact all Service Inquiry (SI) reports, in accordance with the FOI Act, prior to release. This includes the removal of personal information, and Operational or commercial information deemed too sensitive to release into the public domain, amongst other things. In practise, none of the exemptions in the FOI Act applied in this case so the report will be released unredacted aside from the removal of a small amount of personal information
Last edited by airsound; 4th Feb 2014 at 08:15. Reason: bolding
Cunning Artificer
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a trend failure can now only exist in the tail number in question. That is, it may be considered a trend if it occurs more than once in a tail number, but not if it occurs once in every aircraft in the fleet.
Blacksheep
That all sounds familiar.
The debate at the time (given we tried to ignore AMSO's edict) included an interesting question. If the fault was first noticed on the Reference or Sample system, did that count as the first "event"? The answer was, Reference - Yes (because it is held at 24 hours readiness for front line use and is at, or beyond, the In-Service Build Standard) and Sample - No (because, like Hot Rigs, it has known unserviceable LRUs applied to it, so false data is inevitable, and it is almost never at the In Service standard).
The reason I remembered this was because if Martin Baker uncovered the possible over-tightening issue, it may have been on their Reference seat. If that were so, there would be a very formal way of reporting and investigating; quite different from someone, for example, just thinking of the risk or spotting an error in a tech pub.
I still think it inconceivable they did not inform MoD. MoD have admitted so many times now their entire system was is disarray. My bet is MB sent the paperwork to a defunct department/address and it was thrown in file 13. I certainly recall many AMSO and ASE sections at the time changing their titles but retaining their addresses. Anything addressed to the old title was binned, even though it got to the right person in the right office. MB's contract would tell them who the point of contact was. That would take months or even years to be amended. But I'm sure the SI, Coroner and CPS explored all this.
That all sounds familiar.
The debate at the time (given we tried to ignore AMSO's edict) included an interesting question. If the fault was first noticed on the Reference or Sample system, did that count as the first "event"? The answer was, Reference - Yes (because it is held at 24 hours readiness for front line use and is at, or beyond, the In-Service Build Standard) and Sample - No (because, like Hot Rigs, it has known unserviceable LRUs applied to it, so false data is inevitable, and it is almost never at the In Service standard).
The reason I remembered this was because if Martin Baker uncovered the possible over-tightening issue, it may have been on their Reference seat. If that were so, there would be a very formal way of reporting and investigating; quite different from someone, for example, just thinking of the risk or spotting an error in a tech pub.
I still think it inconceivable they did not inform MoD. MoD have admitted so many times now their entire system was is disarray. My bet is MB sent the paperwork to a defunct department/address and it was thrown in file 13. I certainly recall many AMSO and ASE sections at the time changing their titles but retaining their addresses. Anything addressed to the old title was binned, even though it got to the right person in the right office. MB's contract would tell them who the point of contact was. That would take months or even years to be amended. But I'm sure the SI, Coroner and CPS explored all this.
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It's my understanding that previous ejections (involving this Mk of ejection seat)had only succeeded because they were not zero zero ejections, and that MB were allegedly aware of this.
All rumour of course.
All rumour of course.
I thought the issue was more that the RAF had not officially been told, and that there was "no logic" for this?
"my understanding"
is that the RAF were aware, but that it was information that was verbal and "understood" and so nothing official in any manualSeems like a case of poor communication more than anything else as far as MB are concerned. What would be the reason for them to withold information that the seat could fail in zero/zero conditions if this bolt was over-tightened, when they had admitted as such to many other organizations?
Mods/upgrades/advisories are carried out constantly as issues are found on seats, why would this issue be any different?
What would be the reason for them to withold information that the seat could fail in zero/zero conditions if this bolt was over-tightened, when they had admitted as such to many other organizations?
Mods/upgrades/advisories are carried out constantly as issues are found on seats, why would this issue be any different?
Mods/upgrades/advisories are carried out constantly as issues are found on seats, why would this issue be any different?
Lacking precise detail (because MoD omitted it in court and in all likelihood no-one knew to ask), the key is a proper contract being in place. This has not been MoD policy for over 20 years (which coincides with the reported timeframe) and, as I said in a previous post, there are well documented cases of companies giving up and refusing to work for nothing. If or when a contract was later let, the gap was never filled retrospectively, which translated into missing information in tech pubs.
Not saying this is what happened here, but it is the starting point. It is entirely possible that MB sent the information, but there was no-one in post to process it. There is still much to do, and many MoD staff involved, after the initial notification hits MoD. The various ART reports of the early-mid 90s are consistent in this area - it was not funded and much work was not done.
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I don't mean to speak out of turn here, but all these posts about complex administrative details, seem to forget that it's the technician at the 'Sharp end' who really has the final say in flight safety (Along with those who actually have to fly the machines)
A post on this thread awhile back struck a chord... If it had been a junior erk sat in the seat when it fired, I think there could possibly be a general assumption that it was his, or her fault.
It appears to me, that flight safety is very 'Top down' these days, given the plethora of administration, publications & the general dismissal of experience of those on the 'Coal face'.
It's a two way thing in my opinion, those on the 'Coal face' can't usually work out the fatigue life of an airframe for example, yet they know the inner workings to a fine degree.
It's the idea of complex administration, with guys on the ground 'Robotically' following instructions, which is wrong on so many fronts.
This post is somewhat off topic, but was prompted by all the posts about the 'Top down' administration.
A post on this thread awhile back struck a chord... If it had been a junior erk sat in the seat when it fired, I think there could possibly be a general assumption that it was his, or her fault.
It appears to me, that flight safety is very 'Top down' these days, given the plethora of administration, publications & the general dismissal of experience of those on the 'Coal face'.
It's a two way thing in my opinion, those on the 'Coal face' can't usually work out the fatigue life of an airframe for example, yet they know the inner workings to a fine degree.
It's the idea of complex administration, with guys on the ground 'Robotically' following instructions, which is wrong on so many fronts.
This post is somewhat off topic, but was prompted by all the posts about the 'Top down' administration.
Last edited by Flight_Idle; 4th Feb 2014 at 21:26.
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Finally...
Walbut:
"As a follow on, the T Mk 2 and later Hawks has a 'PINS' caption on the CWP. If I remember rightly it illuminates if the pins are left in with the canopy closed. It was introduced to try and prevent one of the other hazards associated with seats, leaving the safety pins fitted during flight."
I recall this being discussed in the early '90's and originated from a test pilot, familiar to many here, who made the dreadful discovery that he'd flown a sortie with the pins still in (though he wanted it linked to the engine turning). He had gone on about this until he retired and just couldn't get anyone to implement the idea. I've often thought that there is a general ethos in aviation to leave stuff alone for some unfathomable reason and it is a real struggle to get any innovation or improvement made until an accident or incident forces action.
Perhaps an improvement or a correction is seen as an admission that it wasn't perfect in the first place. In the real word nothing ever is.
"As a follow on, the T Mk 2 and later Hawks has a 'PINS' caption on the CWP. If I remember rightly it illuminates if the pins are left in with the canopy closed. It was introduced to try and prevent one of the other hazards associated with seats, leaving the safety pins fitted during flight."
I recall this being discussed in the early '90's and originated from a test pilot, familiar to many here, who made the dreadful discovery that he'd flown a sortie with the pins still in (though he wanted it linked to the engine turning). He had gone on about this until he retired and just couldn't get anyone to implement the idea. I've often thought that there is a general ethos in aviation to leave stuff alone for some unfathomable reason and it is a real struggle to get any innovation or improvement made until an accident or incident forces action.
Perhaps an improvement or a correction is seen as an admission that it wasn't perfect in the first place. In the real word nothing ever is.
The 'pins left in ' scenario should not happen with most RAF Hawks - as most RAF Hawks have the modified pin stowage on the port glare shield,thereby giving the grouncrew an excellent view of pin location.
The original pin stowage on the left canopy longeron was not as safe because if the pilot forgot his pins - it would not really be obvious to the groundcrew !
Ironically the Reds have the canopy stowage because the 'smoke on' indicator lights are up on the glare shields.
There is one other UK based hawk with the canopy pin stowage in the rear cockpit because of lack of space on the glare shield.
The original pin stowage on the left canopy longeron was not as safe because if the pilot forgot his pins - it would not really be obvious to the groundcrew !
Ironically the Reds have the canopy stowage because the 'smoke on' indicator lights are up on the glare shields.
There is one other UK based hawk with the canopy pin stowage in the rear cockpit because of lack of space on the glare shield.
It's the idea of complex administration, with guys on the ground 'Robotically' following instructions, which is wrong on so many fronts.
This process set the standards for the sharp end to comply with, and the primary output is a verifiable Safety Case, without which the aircraft cannot fly. One of the problems in this accident was a complete breakdown of this process, and it is vitally important to understand why because it is indicative of systemic failures. One of the reasons, almost certainly, is the reduction in engineering posts (something mentioned at the Inquest, and not confined to front line - in fact, front line have survived longer than most).
I think the underlying causes of this accident are going to be complete no-brainer. The real problem may be that MoD no longer have anyone junior and experienced enough to understand. They have plenty of senior staff who don't begin to understand. It certainly wasn't reported that anyone came remotely near the truth in court, but perhaps tomorrow we'll see if the SI got there.
It was mentioned at the inquest that the ground crew had reminded him to stow his pins.
Flight Idle
Absolutely spot on.
But to be fair to maintainers throughout MoD and industry, if the powers that be stop funding MF765s (Unsatisfactory Feature Reports) altogether, then it is natural that an apathy will will set in because one never gets an answer. Time after time this system failure has been escalated up the Star ladder by the Inspector of Flight Safety; if they ever bothered to respond it is along the lines of "shoot the messenger". The same people succeed in hiding their failures because they dictate the scope of any investigation, thus judging their own case, which is why MoD only looks at the final act (the pilot or maintainer). How many BoI/SI reports have cited "Organisational Fault" as a factor? Nimrod XV230 came close (ACM Loader) but didn't use the words. The rules should require a positive statement; not an implication that just because they don't mention it everything is ok.
Absolutely spot on.
But to be fair to maintainers throughout MoD and industry, if the powers that be stop funding MF765s (Unsatisfactory Feature Reports) altogether, then it is natural that an apathy will will set in because one never gets an answer. Time after time this system failure has been escalated up the Star ladder by the Inspector of Flight Safety; if they ever bothered to respond it is along the lines of "shoot the messenger". The same people succeed in hiding their failures because they dictate the scope of any investigation, thus judging their own case, which is why MoD only looks at the final act (the pilot or maintainer). How many BoI/SI reports have cited "Organisational Fault" as a factor? Nimrod XV230 came close (ACM Loader) but didn't use the words. The rules should require a positive statement; not an implication that just because they don't mention it everything is ok.
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I seem to remember when the first Chinooks came into service the manuals were printed on yellow paper, as they were used and problems were found they were amended and they came out in white,that way you could see pages that needed checking against the aircraft, and those that had been corrected, eventually we ended up with a working copy.
The old pin stowage is quite visible from the outside. The reason it was moved was to put it more into the pilot's view to try to prevent him forgetting it.
It was mentioned at the inquest that the ground crew had reminded him to stow his pins.
It was mentioned at the inquest that the ground crew had reminded him to stow his pins.
The trouble with the 'old' stowage was that if the pilot forgets - and the start crew does not notice/or distracted - then it does not really stand out...the pins show very well if stowed but there is no highlight if not stowed !
At #236 I said;
Answer now available. The vast majority.
"Ensure safety critical components meet design specification"
"Ensure risk are tolerable and ALARP"
"Ensure project teams have a robust and auditable method of tracking, reviewing and managing airworthiness decisions"
"Ensure the project team maintains safety cases"
"Ensure the document set accurately reflects maintenance procedures"
And so on. 1st year apprentice stuff throughout. Anyone with more experience should be utterly embarrassed at having to be reminded of this. The very fact they have to make such recommendations means very senior heads should roll over this. And yet a year ago the CPS said there was insufficient evidence.... Time to reconsider.
59 recommendations in the SI report. All accepted apparently.
I wonder how many fall into the "mandated policy anyway" category. Most in the Nimrod Review did.
I wonder how many fall into the "mandated policy anyway" category. Most in the Nimrod Review did.
Answer now available. The vast majority.
"Ensure safety critical components meet design specification"
"Ensure risk are tolerable and ALARP"
"Ensure project teams have a robust and auditable method of tracking, reviewing and managing airworthiness decisions"
"Ensure the project team maintains safety cases"
"Ensure the document set accurately reflects maintenance procedures"
And so on. 1st year apprentice stuff throughout. Anyone with more experience should be utterly embarrassed at having to be reminded of this. The very fact they have to make such recommendations means very senior heads should roll over this. And yet a year ago the CPS said there was insufficient evidence.... Time to reconsider.