Flt. Lt. Sean Cunningham inquest
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Just finished reading the report... The facts can be understood, an unfortunate series of errors, compounded by an engineering anomaly... Either one may have been mitigated, in different circumstances, but when combined were sadly incompatible with survival...
The report went far deeper than I would have expected, into the culture of the 'Reds', I hardly dare comment, based on what I have read.
The report went far deeper than I would have expected, into the culture of the 'Reds', I hardly dare comment, based on what I have read.
Slightly off topic.
I couldn't find the detail in the report, but what happened in the inadvertent hawk ejection from 1983 that was referred to?
I couldn't find the detail in the report, but what happened in the inadvertent hawk ejection from 1983 that was referred to?
Last edited by JFZ90; 6th Feb 2014 at 21:49.
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Speaking about the findings, retired Air Vice Marshal Jerry Connelly, said: "This isn't something that has crept in over the past couple of years - I suspect it goes much further back in time - and whatever the structure of the air force there has been a chain of command at the top, monitoring and allowing the team to actually perform."
He added: "I cannot believe this has all come as a big shock to them and its hard to understand why they were not doing something more active to change that drift."
He added: "I cannot believe this has all come as a big shock to them and its hard to understand why they were not doing something more active to change that drift."
Was he disappointed not to become an Air Marshal?
Is he now a 'consultant' earning money in the civvy sector?
Well, I've only skimmed the report, and it is impressively detailed as usual.
I can't help thinking:
- this accident was truely tragic, as stated in the report
- it does seem to me to be mainly technical in nature, the ops stuff is concerning, but largely unconnected with the actual incident IMO.
Final thought - don't know how many lives the Mk10 has saved, but must be up there as one of the most successful live savers ever. That shouldn't be forgotten.
I can't help thinking:
- this accident was truely tragic, as stated in the report
- it does seem to me to be mainly technical in nature, the ops stuff is concerning, but largely unconnected with the actual incident IMO.
Final thought - don't know how many lives the Mk10 has saved, but must be up there as one of the most successful live savers ever. That shouldn't be forgotten.
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the ops stuff is concerning, but largely unconnected with the actual incident IMO
The Dominator probably won't.
Discipline!
That's what these young chaps need. More discipline!
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- it does seem to me to be mainly technical in nature, the ops stuff is concerning, but largely unconnected with the actual incident IMO.
The constant thread running through accident reports is that the paperwork was wrong.
Only two things can cause this.
Either:
A Being slack with paperwork makes you crash.
or
B People who are slack with their paperwork are more likely to crash.
It may of course be that all squadrons are as shabby at keeping in line, but if that's the case, why?
I've been reading some more service inquiry reports, and apart from the appalling grammar and spelling errors, (very like the AAIB reports) there is that ever present history of errors leading up to the crash.
The fudging of hours for IR recency or CT hours might have no bearing on this particular tragedy, but what kind of culture is it exposing?
What's it going to take for someone to have the balls to find and discipline the officers who failed to find the shortcuts? I know it will not bring Flt Lt Cunningham back, but it might well keep Flt Lt Bloggs alive next year.
Since DLT can be put in the dock for "allegedly" feeling up a girl on Top of the Pops 40 years ago, surely even a Group Captain can be held responsible for his actions (or lack thereof) as a Squablin Bleeder five years ago.
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The constant thread running through accident reports is that the paperwork was wrong.
Only two things can cause this.
Either:
A Being slack with paperwork makes you crash.
or
B People who are slack with their paperwork are more likely to crash.
Only two things can cause this.
Either:
A Being slack with paperwork makes you crash.
or
B People who are slack with their paperwork are more likely to crash.
My experience, based upon reading hundreds of accident reports over a few decades, is that investigations almost invariably disclose inaccuracies in paperwork.
However, the same is true of investigations for other (non accident) purposes.
It is extremely rare that very close scrutiny of any human activity fails to disclose inaccuracies in paperwork.
In relation to accidents:
Far more often than not, the inaccuracies had no bearing whatsoever, directly or indirectly, upon the accident.
FL
Last edited by Flying Lawyer; 6th Feb 2014 at 23:58.
Agreed, sort of; from my time as a Station Flight Safety Officer, admin errors were at least a minor contributory cause in over 30% of accidents, and occurred in both BoIs I had to organise.
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So, Flying Lawyer, would Your paperwork stand up to scrutiny then?
If, the last time that you piloted an aircraft, you had been "ramp checked" would you have failed to be able to show compliance with the regulations?
If, the last time that you piloted an aircraft, you had been "ramp checked" would you have failed to be able to show compliance with the regulations?
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Fox3, do you think that if the culture is to allow the paperwork to be "there or thereabouts" then the spirit of other checks and balances may be cast aside as well?
The admin errors can occur at any point in the system, from Orders, manuals, even unofficial (but highly useful) 'guides'. Was my paperwork ever in error? Not when I or anyone else formally checked, no. But I am not so arrogant as to claim it never was on all the occasions I wasn't checked. OTOH, maybe that's why they made me a Station Flight Safety Officer!
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maybe that's why they made me a Station Flight Safety Officer
Or....................
Maybe that's why you didn't feature in a Service Inquiry.
Airpolice - It's a risk, certainly. In my time (80s, early 90s), accidents occurred that showed the risk is higher in small/unique units. There is always the balancing factor that the aim of an Armed Force is not just to complete paperwork. I can remember certain paperwork stats that were literally impossible (because certain aircraft/equipment no longer existed), yet insisted on by NATO. Do you lie and fill in the 'We've done it box', or cause a whole load of aggro (which won't fix the problem) and tell the truth? What most (and I) did was to lie, but make a special point not to let lying become a habit.
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So, would Your paperwork stand up to scrutiny then?
If, the last time that you piloted an aircraft, you had been "ramp checked" would you have failed to be able to show compliance with the regulations?
My fundamental disagreement is with your proposition that "Only two things can cause this."
I have seen instances where sloppy paperwork has been an indication of a sloppy operation/pilot, but it doesn't by any means necessarily follow.
FL
Below the Glidepath - not correcting
- it does seem to me to be mainly technical in nature, the ops stuff is concerning, but largely unconnected with the actual incident IMO.
The "ops stuff" was indicative of the organisational failings that had happened over a number of years. Tragically, the lightning rod for these failings was the technical failure of the drogue shackle. The "ops stuff" that got the poor soul into this position are manifest throughout the report. There were numerous opportunities to break the chain, but they were all missed. The avoidance of poor seat pin drills, incorrect seat stowage post flight, ineffective engineering oversight and a different flight safety ethos could all have taken fate on a different course that day, but because all those factors existed, the drogue shackle failure proved to be fatal. The "ops stuff' got him to the scene of the accident as fast as any other cause would have done on the day.
I'm with FL on this one.
AirPolice's point.
b. Pilots who are slack with paperwork are more likely to crash,
is true in my experience,
but there are a very large number of other factors, as the Board found in this case.
At the root, this accident was caused by it being not generally known that the Seat Pan Handle could be partially raised (I have about 800 hrs on Mk10 seats, and I didn't know this till now) and it not being at all easy to see this, and that the scissor shackle bolt was overtight by 0.009 inches.
AirPolice's point.
b. Pilots who are slack with paperwork are more likely to crash,
is true in my experience,
but there are a very large number of other factors, as the Board found in this case.
At the root, this accident was caused by it being not generally known that the Seat Pan Handle could be partially raised (I have about 800 hrs on Mk10 seats, and I didn't know this till now) and it not being at all easy to see this, and that the scissor shackle bolt was overtight by 0.009 inches.
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FL, perhaps I should have made the Tounge in Cheek aspect of my "only two things" comment clearer.
Obviously there can be many causes, and sometimes no connection. But who can really believe that Coiln Macrae would have survived until today if he'd carried on flying with such scant regard for the rules?
Like you, I just drive puddle jumpers belonging to a variety of other people. I was referring to the simple paperwork that we are subject to.
One outfit that I hire from have never seen my licence or logbook. One FI there did ask me one day if I had it with me, and on being told that it was in my bag, he was satisfied.
Another operator is at the other end of the scale and on returning there after a break of almost three years, to the club where I passed my skills test, I was required to produce, as part of my check ride, my licence, log book and medical. I'm not afraid of being asked to produce it instantly, because I can.
This club keeps a note of all relevant expiry dates for all pilots and we are all subject to making public our recency compliance, for all club members to see.
My point about the accident reports is that there is a high incidence of "the deceased was flying without the right paperwork" so how many others are doing the same but we don't hear about it until they are dead?
The SI into the incident at Scampton has shown some big lapses in management of the regulated documentation. How many times will this need ot come up before the rest of the RAF takes a good look at how they are doing things?
Perhaps nobody cares because they are not going to have their bum felt for it even if they do get caught. No amount of looking at squadron flying hours and IR recency or dual checks on the aircrew woud have made the seat work. That's no reason not to flog someone for letting the side down.
Obviously there can be many causes, and sometimes no connection. But who can really believe that Coiln Macrae would have survived until today if he'd carried on flying with such scant regard for the rules?
Like you, I just drive puddle jumpers belonging to a variety of other people. I was referring to the simple paperwork that we are subject to.
One outfit that I hire from have never seen my licence or logbook. One FI there did ask me one day if I had it with me, and on being told that it was in my bag, he was satisfied.
Another operator is at the other end of the scale and on returning there after a break of almost three years, to the club where I passed my skills test, I was required to produce, as part of my check ride, my licence, log book and medical. I'm not afraid of being asked to produce it instantly, because I can.
This club keeps a note of all relevant expiry dates for all pilots and we are all subject to making public our recency compliance, for all club members to see.
My point about the accident reports is that there is a high incidence of "the deceased was flying without the right paperwork" so how many others are doing the same but we don't hear about it until they are dead?
The SI into the incident at Scampton has shown some big lapses in management of the regulated documentation. How many times will this need ot come up before the rest of the RAF takes a good look at how they are doing things?
Perhaps nobody cares because they are not going to have their bum felt for it even if they do get caught. No amount of looking at squadron flying hours and IR recency or dual checks on the aircrew woud have made the seat work. That's no reason not to flog someone for letting the side down.
yes, its very sad - you look at the SPH now and think that is an obvious issue, but its clear it wasn't obvious for years for hundreds of users. Easy in hindsight.
similarly with the shackle, its obvious when you look at the design that it shouldn't be tight enough to pinch, and actually it seems clear that this was kind of known for over 20 years, but sadly on this occasion it was also missed. The tech pubs should clearly have spelt it out, but given the consequences, it is unfortunate that the risk of pinching was not designed out in the first place. Easy in hindsight.
similarly with the shackle, its obvious when you look at the design that it shouldn't be tight enough to pinch, and actually it seems clear that this was kind of known for over 20 years, but sadly on this occasion it was also missed. The tech pubs should clearly have spelt it out, but given the consequences, it is unfortunate that the risk of pinching was not designed out in the first place. Easy in hindsight.
I couldn't find the detail in the report, but what happened in the inadvertent hawk ejection from 1983 that was referred to?
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My point about the accident reports is that there is a high incidence of "the deceased was flying without the right paperwork" so how many others are doing the same but we don't hear about it until they are dead?
I don't accept the validity of the link you seek to make.
That's no reason not to flog someone for letting the side down.
Failings which emerge during the course of a fatal accident investigation should not be dealt with more harshly simply because there was a fatal accident.
If a failing is proved to have caused an accident, or proved to have contributed to it, different considerations apply. (NB. Proved. Not speculation that a failure to enforce or comply with rules/regs might have contributed in some indirect way to the accident.)
Much has clearly been learned from the investigation into this tragedy, and there are some findings of systemic failings. I don't share your desire to to try to find people to punish. (Or scapegoats.)
FL