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Flt. Lt. Sean Cunningham inquest

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Flt. Lt. Sean Cunningham inquest

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Old 7th Feb 2014, 14:54
  #441 (permalink)  
 
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558, it seems that for the RAf to move on and improve, the incident needs to be considered, and dealt with, as three distinct things.

The seat firing.

The seat failing.

All of the dirt that was exposed by the inquiry into the first two events.
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Old 7th Feb 2014, 15:44
  #442 (permalink)  
 
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I once worked for an IT company where all managers were set performance targets. Some targets conflicted with each other. If you achieved one you had to let slip another one. Some targets were nigh on impossible to achieve in a busy and competitive market place. Promotion, salaries and even job security were based on these targets so people fiddled and cheated. However as long as a set of 'achieved' target figures were presented to the senior management, they didn't ask questions, as business was very good! The auditors were the ones to watch out for!
Could it be, that with the highly visible and at times, intensive workload of the RAFAT, priority was given to the tasks that were highly visible?
The deliberate falsification of continuation training, instrument flying and instrument approach records were neglected because it may have been nigh on impossible to achieve both these tasks and the displays, which of course, was their raison d'etre.
From my business experience it's an easy and pervasive culture to slip in to
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Old 7th Feb 2014, 16:11
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Is it possible to permanently install a small mirror to the aft face of the control column, such that the seat occupant would be able to view the correct installation of the pin, moving the column as required to optimise the viewing angle?
Use an inspection mirror on the A/F and B/F, or motor the seat to the correct (non Red Arrow) position.

By the way what does the the A/F and B/F documentation say for the tradesmen checking the ejection seat. Gets no mention in SI. Perhaps it is another piece of paperwork that has gone missing, or never updated.

DV
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Old 7th Feb 2014, 16:20
  #444 (permalink)  
 
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The deliberate falsification of continuation training, instrument flying and instrument approach records is a wholly different matter to mere forgetfulness.
I am loathe to condemn any aviator, and won't.

If you recall the Mull of Kintyre evidence, the Aldergrove detachment was criticised for poor paperwork practices. But the reason apathy set in was because VSOs had stopped funding e.g. fault investigations, and Engineering Authorities had been instructed not to seek investigations. In 1991 all such engineering decisions on airworthiness related faults were in the hands of very junior Supply Managers at Harrogate. (This evidence, and actual letters, were given in evidence to Lord Philip). The front line were criticised by the ZD576 BoI, but the underlying system failure was not even mentioned. Same as this current case.

While perhaps worse, I think one will find a similar underlying reason why the Red Arrows pilots thought they could falsify documents. After all, they must have known it is a specific offence under, for example, the Air Force Act. Someone condoned it.

If Court Martialed, their defence will be interesting. They don't need to look far for precedent....

Exhibit A - ACAS's false Chinook Release to Service in November 1993. Was he instructed to do this? We don't know, but Lord Philip confirmed the RTS was in every way a false representation of the facts. And there is no doubt his fellow VSOs knew what he did. After the crash, Wratten even wrote him a letter asking when the aircraft was due to be airworthy.

Exhibit B would be a series of four letters between 28.11.12 and 13.2.13; three from DE&S policy branch and one from the Head of the Civil Service. All four uphold previous rulings, by the RAF and PE/DPA that refusing to obey an order to make a false declaration is an offence, but issuing that order is not an offence. The December 1992 ruling by the RAF Chief Engineer's immediate subordinate was the subject of a 3.5 year investigation, which advised PUS the ruling was wrong. Yet, the policy remains extant.

If the Reds are reading this, and you find yourself in the dock, let me know because I'd love to see what happens when those policy rulings are read out in court. Then we'd maybe have a chance of seeing the real culprits answer for their actions. Also, have your representative call the Provost Marshal, as he has this evidence but declined to act upon it. I'll send him another copy.
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Old 7th Feb 2014, 16:20
  #445 (permalink)  
 
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Easy street:-
One other thing - it's the Military Aviation Authority so it can focus on whatever aspect of an accident it feels appropriate, not just airworthiness!
If that's aimed at me, Easy, I wasn't implying that it was called anything different. What I was trying to say is that UK Military Airworthiness Authority is vested in the MAA.


There would be no point in it being called the Military Airworthiness Authority for the simple reason that it doesn't do airworthiness, for the simple reason that it doesn't get airworthiness. If it did, it would cut itself adrift from the MOD and from the MAAIB and get to reinstating the enforcement of the perfectly good regulations that tuc speaks of, instead of wasting its time and effort in writing new 'workaround' ones.


It is a matter of great urgency that it be independent of the MOD and of the MAAIB, for only then can we expect it to take airworthiness seriously enough to carry out its principal function, ie to ensure that avoidable accidents are avoided. Ditto all the above with the MAAIB.


Self Regulation Doesn't Work and in Aviation it Kills!
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Old 7th Feb 2014, 18:18
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Tuc,

If the RAFAT pilots end up in the dock it sounds as if they would be totally bemused - they are probably amazing at seeing fault in formation flying but completely unable to identify right from wrong otherwise.

After all, they think a minute or so is enough to check their SE and change. They are alone in military aviation in thinking that rushing is good and checking is bad. They think they can wear what they want. They don't really see the need to check the F700. They don't think training records are a good idea. They are happy to lie about sim time, CFT, actual and approaches. Their head shed don't really understand how their engineers are trained. Flight safety meetings are someone else's issue, and FRCs are at best suggestions. A mid air and previous tragedy weren't enough to shake them from the very depths of poor behaviour. What gives you the impression that a CM will manage?

I fondly imagine they would go for blank looks or simply trot back to a 'you're not one of us - you wouldn't understand' defence.

I think we can divide this neatly. There are endemic air worthiness issues which allowed an ejection seat to malfunction once fired. However it fired, in large part, because it was used by a unit that was rotten to the core.
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Old 7th Feb 2014, 22:21
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Wow!!
What experience have you had of the RAFAT that generated such a bitter and defamatory post? whatever it was has clearly traumatised you.
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Old 7th Feb 2014, 23:00
  #448 (permalink)  
 
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Clockwork Mouse, have you read the SI, in particular the sections on culture, flight preparation etc? It is clearly written, evidenced and in my view damning. I can see why SLW has reached his conclusions, although they may be a tad OTT considering the tragic circumstances of this thread.
The SI uses a number of theories to explain why cultures like this can begin and perpetuate. Gouldie's post shows to highlight how people can fall into the trap of believing that everything is fine "our core output is IT/doing air shows etc. and that's going well so everything else must be fine".
The Reds are not the only unit to suffer from small unit syndromes such as these, look at the SI into the almost sinking of (now former) HMS Endurance on the same gov.uk website to see some very similar themes.
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Old 7th Feb 2014, 23:21
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Yes, I have read it.
The section on culture etc is a disgrace. It describes a recent social psychology theory which has some, but not complete, acceptance among sociologists and, without any supporting evidence, states that it might be applicable to a close knit, elite unit like RAFAT and, if so, might have been a contributory factor. Theory dressed up as fact. And yes, I am a psychologist.
I would also not be surprised if you discover in due course that the allegations of misconduct in pilot training record keeping are on very shaky evidence and much more limited than the block smearing of the report implies.
RAFAT bashing in the intemperate terms expressed by SLW are disgraceful in my view. But then I am but a Pongo, albeit an educated and broad minded one.
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Old 8th Feb 2014, 00:09
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Enough please. What has not been exposed and probably never will be is the following:

1. The 'falsification of records' relates to two sorties. The first, when CT serials were entered into the auth sheets after each pilot flew a CT sortie. Doubt was cast by the SI over the amount of time the pilots had to fulfil these serials. No evidence was provided that this could not have been done in the time logged. The second was noticed in Flt Lt Cunninghams logbook, after the SI noticed he had entered a 40 minute sortie when the auth sheets showed 35. After an investigation, this issue was cleared.

2. The SI knowingly printed in their report an incorrect 'timeline'. They were informed of the errors in their timeline by the Team Leader but chose to ignore the actual timeline used. The actual timeline gives an additional 4 minutes from step to walk from that printed in the report (12 mins), which allows the pilots plenty of time to complete ALL checks, F700 etc. Also, the SI references the RAFAT timeline against other Hawk users which is misleading in the context of RAFAT ops. A RAFAT brief takes between 5-15 minutes, which includes all domestic aspects of the sortie, an emergency, loser plan and out-brief. Extensive use of SOPs helps greatly in this regard. The SI NEVER observed a RAFAT brief-walk-chek-in-taxy-take-off so has no context. Some of you question integrity...

3. The sim issue is irrelevant as the amount of time flown in the sim counts towards nothing. The pilots were completing their emergency sims in approximately 35-40 mins, more than enough time to complete the required emergencies and this is backed up by the testimonies of the sim instructors. Claiming one hour in your logbook for the sim might not be correct, but it is irrelevant to any currencies as the sim counts for nothing except a 'tick' that an emergency sim has been conducted. Also, currencies were questioned in the context of the number of sims conducted per year. This relates to a technicality in the Reds Display Directives that states that 6 sims should be completed annually. This was only in the Directives as the 22 Gp sim currency is 2 months. However, the Team are allowed a 1 month extension (3 months total) at the discretion of the DDH (Cmdt CFS) which they use every year when they go to Cyprus. So every year, they do 5 (and a half) but are always 'current'. This 'error' in the Directives has been amended with the removal of the '6 per year' line. Incidentally, all non-22 Gp Hawk operators (100 Sqn and the Navy have 3 month currencies for emergency sims). This issue was investigated and cleared.

4. The ONLY difference the Reds had to aircraft checks was the following: the FRCs say to close the canopy, remove pins and then start the GTS. These checks had been modified decades before to the following: Start the GTS, close the canopy (while the GTS is starting) and then remove pins. Engine is then ready to start as it takes 20 secs for the GTS to come online. While this may have been incorrect iaw the FRCs, this procedure had never been questioned by annual FSV, CFS Trappers (the Reds do them annually, not every 2 years as stated by Orders) or any external visitors, of which their are dozens every year. The reason the Team did this was to warn all engineers that the canopies were about to be closed and that they should 'hide' under the aircraft in case of inadvertent MDC initiation. With up to 11 aircraft starting at once and lots of engineers close to the aircraft, this was considered best practice but has since been changed.

5. The SI claimed that pilots were logging IF when they (the SI) believed the weather conditions did not allow it. They went through met records for one day during the 2011 display season when all pilots claimed IF. Met records showed BKN cloud up to 9000ft on this day and the SI did not believe this was enough to fly on instruments. BKN can be 5-7 octas of cloud and they based this accusation on this. This issue was investigated and cleared.

6. As a result of the conduct of this SI, the SI process itself is being looked at by the MAA (new DG) with a view to modification; specifically the right of reply by the Service. While some good work was undoubtedly done by elements of this SI, especially regarding the over-tightening issue and the forensic level examination that looked at how the handle MAY have been moved into an unsafe condition, many of the 'other factors' were opinion-based with little solid evidence to back them up. Many of them were thoroughly investigated and cleared, yet they remain in the report.

7. While there was no mandated Air Safety Management Plan completed by the Cmdt at the time, it had been started. When Eggman was killed, the Cmdt made the decision to spend his time with the Team and look them in the eye every day to make sure they were good to go, instead of sitting in his office writing this management plan. He ultimately pulled the plug on RAFAT flying in early September (2 weeks before the end of the 2011 season) over concerns with one of the pilots who was not coping well. If he had not, there may well have been an accident. In my eyes, that is good supervision.

There will always be those of you who will want to believe every aspect of this SI and how gash the Reds might be, but I would urge caution before you jump to conclusions. They are every bit as professional as they were when they were on the frontline and take great pride in what they do. Please consider what I have taken the time to write before you have hung the Team as guilty.
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Old 8th Feb 2014, 01:16
  #451 (permalink)  
 
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Inshala

How dare you bring reasoned debate and first hand knowledge to the table. You should be well aware by now that supposition and hearsay are far better tools for this forum!
I've thought long and hard before commenting on this thread since I know all of the guys involved and it wouldn't be a stretch for them to work out who I am. The fact is that I have flown with them many times before and I would fly with any one of them again tomorrow.
I've been around long enough to know how FJ units and SIs work. Whilst some aspects of the report make for bad reading it does not paint them in the light that I myself have witnessed first hand. I would struggle to find a more professional, focused and competent bunch. There are those on here who will love to knock them and believe what they hear about them being a bunch of arrogant prima donnas but unless you know them personally or have flown with them you really do not know what you're talking about.
Trust me when I say there's a reason they are held in such high regard by the public. They are bloody good at what they do and have suffered from a period in their history that would make many grown men weep.
Please remember when you publicly denounce them (from the safety of your internet anonymity) that they live a very different life to your average FJ pilot and that brings with it good and bad. Having my name dragged through the mud on here wouldn't make me very happy and I'm sure you'd all feel the same.
I probably won't post on this thread again since I don't want to enter into any heated debates on the subject but just felt I should add what support I can offer from a standpoint of someone who actually knows the guys and has flown with them.
BV
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Old 8th Feb 2014, 06:21
  #452 (permalink)  
 
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Inshala, if there was such a discrepancy between the SI and your narrative, surely an official complaint would have been raised before it was released to genpub access?

Moreover, the SI stated that more than one pilot was flying without a valid IR. I found that strange as I was under the impression that military IR validity is maintained by test, not experience - but perhaps things have changed over the years.

The SI paints a bleak picture of RAFAT culture and practices; if that picture is (hopefully) as incorrect as you allege, then 'an MoD official' needs to come out and confirm your views. Otherwise it will simply go unchallenged and people will be none the wiser.
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Old 8th Feb 2014, 06:38
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Inshala, I'm sure there are people who will be convinced by your allegations that everything is fine and the SI is a stitch up.

For me, the telling part is the way in which you simply dismiss the bits that you don't want to claim are untrue.

Claiming one hour in your logbook for the sim might not be correct
This relates to a technicality in the Reds Display Directives
While this may have been incorrect iaw the FRCs,
this was considered best practice but has since been changed.

They are every bit as professional as they were when they were on the frontline
In that last bit, are you suggesting that other service pilots are signing false reports because "it's all good" even though the paperwork is wrong?

Why was it so difficult for someone to say, "we only need 40 minutes in the sim, not an hour" and get the paperwork changed?
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Old 8th Feb 2014, 08:04
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Why was it so difficult for someone to say, "we only need 40 minutes in the sim, not an hour" and get the paperwork changed?
Agreed

The same applies for any other instances of "pencil whipping" that may have gone on. If the recurrent training/ continuation training requirement does not fit in with the RAFAT's bespoke operation, or is not achievable given the demands placed on the Reds then somebody needs to "man up", to use the current vernacular, and get the rules reassessed/rewritten.

Wiggy,

Former Sqn "stats" officer and chaser of the SD98 rate, .....and if asked I will tell you I never sharp pencilled anything....
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Old 8th Feb 2014, 08:30
  #455 (permalink)  
 
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"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?"

Perhaps it showcases an issue familiar to many on the Front Line; namely that VSOs need a plethora of currency 'requirements' and computer based tracking tools to copper-bottom themselves against comeback whilst providing unrealistic targets and insufficient resource to achieve the task. Why? They've continued to perpetuate the myth that you can cut resource and increase output...because the previous incumbents of their jobs managed it why can't they? Final proof perhaps that there are more 'be-ers' than 'do-ers' at the top of the RAF.....

Oh for a system that bred supervisors and VSOs that understood the issues and constraints, rather than hide behind a computer spreadsheet and say 'all was well on my watch...'.
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Old 8th Feb 2014, 09:06
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I cannot vouch for the conduct of RAFAT as a unit, because I have no personal knowledge of it. What I would say is that the criticism made of it in this SI bears a familiar ring from previous SIs/BOIs. What did the Mull pilots have for breakfast? Did they have any at all? In that case it acted as a diversion from the elephant in the room, that the aircraft was grossly unairworthy and was flying under an illegal RTS.


Mull showed clearly that lying, stealing, and cheating existed at the very top of the RAF High Command. Illegal orders were issued by Air Rank Officers who are still not condemned, only those who refused to obey them are. If such an example is set by those in High Command, it is only a matter of time before such practice appears at a unit near you!


RAFAT may well need attention in that regard, again I do not know, again I take what the MOD says, through its MAA subsidiary, with a pinch of salt. What does need attention is the RAF High Command. By protecting their predecessors they continue to compromise Air Safety. While the UK Military Airworthiness Authority remains in house, vested in the MAA (see what I did there Easy Street?) that will continue to be the case. While the MAAIB remains in house and within the MAA, it will continue to be the case.


The MAA has been judge and jury in its own regard. This aircraft was unairworthy. That is the elephant in the room!


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Old 8th Feb 2014, 09:16
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I have to be very careful here, but to keep things on course some facts may reassure some people that due process has been followed:

- Any irregularity that could, at first sight, appear to be a serious service offence has been thoroughly investigated without fear or favour.

- The investigation was not confined to the members of the team at the time.

- The investigation did look at the actions of the senior leadership over an extended timeline.

- The investigation did look at those who had left the Service.

- The decision to charge or to take disciplinary action would have been made at the correct level and did include the Service Prosecuting Authority.

- The matter was referred to Dominic Grieve.

- The SI provided grounds for an investigation, nothing more. Everyone is innocent until proven guilty. The correct people have made the decisions and we must trust their decisions. We must not infer any guilt on any party just by the mere existence of an investigation.

-The thoroughness of the investigation (however painful) should give us confidence, not erode it.

The SI did what it was directed to do; nothing more and nothing less. It was rightly commended by the DG MAA.
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Old 8th Feb 2014, 09:52
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JTO:-
The SI did what it was directed to do; nothing more and nothing less. It was rightly commended by the DG MAA.
Which makes my point succinctly. It should not be up to the DG MAA to commend an investigation by the MAAIB into an airworthiness related accident, but to jolly well get on and carry out its recommendations. One is reminded of the BA737 tragedy at Manchester, when training had to be greatly modified and much extra kit installed in all aircraft on the UK register above a certain size. All that was recommended by the independent AAIB and enforced by the independent CAA on all UK AOC holders.


Am I alone in finding your quote disturbing, in the light of previous BoIs featured in this Forum? They did what they were directed to do. That was the problem.
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Old 8th Feb 2014, 10:21
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All valid points of view, I am merely trying to add some context to each allegation.

BEagle, this was considered, but ultimately it could have delayed the SI and the Inquest and the Team just wanted to put this behind them finally.

While there have been some issues in the past (highlighted by the SI), I know from experience that the Reds are not the only Sqn to have had them. What I would also like to add is that over the past 2 and a half years, the whole Team has changed. They have a new Leader, Wing Commander, pilots, engineers and support staff and every inch of RAFAT business has been extensively looked at and modified if deemed necessary. They have had to endure these years of constant and over-bearing scrutiny, accusations and never-ending inspections and investigations but got on with the job with stoicism and moral courage. They have delivered 2 excellent display seasons, a major foreign tour and non-stop engagement. Ultimately it was the Team that got the Team through it all; now they want to move on and enjoy at least one season of display flying. Of note, they are averaging 6 external inspections per year and have done so since 2011. This would affect any Sqn but the result has been many excellent reports, improvements across the entire Team and probably the most 'compliant' Sqn ever.

If any of you would like to visit Scampton and see for yourself, I would be happy to try and arrange something as I do have one or 2 contacts there.

Enough from me I think and I wish you all well.
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Old 8th Feb 2014, 10:39
  #460 (permalink)  
 
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Originally Posted by Chugalug2
JTO:
Am I alone in finding your quote disturbing, in the light of previous BoIs featured in this Forum? They did what they were directed to do. That was the problem.
Hi Chug,

I was not offering an opinion, just a fact. The ToRs for the SI are available online and are considerably more wide-ranging than pre-MAA precisely to address the concerns you and others have raised.

They do give the panel the ability to question the actions of the MAA and report directly to SofS. They also give the panel (deliberately mixed service with independent oversight) the ability to question the actions of VSOs and hold them to account. You may be in a better to position to judge if this final part is being exercised with the release of another unrelated SI in the coming months.

I know your view on the independence of the MilAAIB but I would genuinely appreciate your view on the scope of the SI ToRs and offer up any potential improvements as they may help to drive a change.

Regards.
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