Flt. Lt. Sean Cunningham inquest
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I know from experience that the Reds are not the only Sqn to have had them.
More importantly, is everyone else now getting "all of their **** in one sock" to ensure that this is the last time that we read about such cultural indifference to regulations?
JTO
I have a problem with at least three of your facts. They may be true in isolation but the SI did not look beyond and assess common failures. It therefore failed in one important duty.
I have a problem with at least three of your facts. They may be true in isolation but the SI did not look beyond and assess common failures. It therefore failed in one important duty.
JTO
Unless I'm wrong a SI, like the BoIs before, has at its disposal a contributory factor called organization failure, or fault? It should say it has definitely eliminated the possibility, not imply it isn't there. The report ignores previous failures that haven't been corrected. I agree with chug. The MAA comments come across as backslapping when what we want them to do is fix the problem. I don't think they even understand it.
Unless I'm wrong a SI, like the BoIs before, has at its disposal a contributory factor called organization failure, or fault? It should say it has definitely eliminated the possibility, not imply it isn't there. The report ignores previous failures that haven't been corrected. I agree with chug. The MAA comments come across as backslapping when what we want them to do is fix the problem. I don't think they even understand it.
Hope this image doesn't distort the page, and apologies for not cropping it (tried but failed!). I assume this is the change in TOR that you refer to JTO. I don't wish to appear churlish, but fear I will. No amount of such workarounds will alter the fact that the MAAIB is part of the MAA which is part of the MOD. Independence is no more divisible than is pregnancy. You are or you aren't. You aren't (independent that is ;-).
dervish, I understand your point and the SI process does not specifically look to directly apportion blame or fault. Clearly by demonstration of the facts, or by informed opinion, it can and should highlight areas of weakness. In this case it did trigger additional investigations and reviews in to what has gone on.
This report did highlight reoccurring issues common to previous SIs; given the short span of time between some of them it is understandable that this should be the case. As for your inference that we have yet to correct all the issues sewn in the past, well in my opinion this is true. Indeed, in some regard I am not convinced we have intellectually accepted that all of the issues actually exist. Again, this is my personal opinion and others are free to differ.
One of the other changes introduced with the MilAAIB and MAA is that the MAA is accountable for ensuring the the corrective actions are tracked and implemented. The MAA is empowered to take direct action against accountable persons - they have done this recently without the catalyst of an actual accident. Over time the cumulative actions of the MAA will feature more and more in reports, especially if corrective action is not actually carried out and just pushed down the road. This is why I support the policy where the SI can investigate MAA actions and report to the SoS via PUS.
This report did highlight reoccurring issues common to previous SIs; given the short span of time between some of them it is understandable that this should be the case. As for your inference that we have yet to correct all the issues sewn in the past, well in my opinion this is true. Indeed, in some regard I am not convinced we have intellectually accepted that all of the issues actually exist. Again, this is my personal opinion and others are free to differ.
One of the other changes introduced with the MilAAIB and MAA is that the MAA is accountable for ensuring the the corrective actions are tracked and implemented. The MAA is empowered to take direct action against accountable persons - they have done this recently without the catalyst of an actual accident. Over time the cumulative actions of the MAA will feature more and more in reports, especially if corrective action is not actually carried out and just pushed down the road. This is why I support the policy where the SI can investigate MAA actions and report to the SoS via PUS.
Chug, that is the change and no, you do not come across as churlish. We (the MoD) have done great harm to ourselves and catalysed the mistrust. I do not claim that all the monsters have gone away but my professional opinion is that there is not a monster under every bed; to claim otherwise only provides a means of obfuscation for those who try to convince us that all is perfect.
Compared to my direct and evidence-based concerns the MilAAIB is one of the true success stories. I do not expect you to take my word for it as history will be a brutal auditor of its actions.
Anyway, enough from me as there are other opinions out there that probably matter more than mine.
Compared to my direct and evidence-based concerns the MilAAIB is one of the true success stories. I do not expect you to take my word for it as history will be a brutal auditor of its actions.
Anyway, enough from me as there are other opinions out there that probably matter more than mine.
JTO
Thank you for that excellent reply.
The report doesn't comment on why the same failures have happened again. Seems the MAA hasn't bothered meetings its own rules. Perhaps the requirement is taken so literally they don't have to look at common denominators? Either way I don't see the point.
Thank you for that excellent reply.
the MAA is accountable for ensuring the the corrective actions are tracked and implemented.
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I note that the SI team states, in summary, that they identified four Aggravating factors, but list only three, and 13 Observations, but list only 12. Either we have a team that can not count, or listed items have been removed by someone, on review.
By the way, none of the 17 Contributing factors caused the death of Flt. Lt. Cunningham; the cause was the failure of the seat to operate correctly. It's like saying that the act of AAR caused the loss of Nimrod XV230, rather than the faulty fuel couplings and hot air pipes.
Come on MAA, you have to do better than this.
DV
By the way, none of the 17 Contributing factors caused the death of Flt. Lt. Cunningham; the cause was the failure of the seat to operate correctly. It's like saying that the act of AAR caused the loss of Nimrod XV230, rather than the faulty fuel couplings and hot air pipes.
Come on MAA, you have to do better than this.
DV
Below the Glidepath - not correcting
By the way, none of the 17 Contributing factors caused the death of Flt. Lt. Cunningham; the cause was the failure of the seat to operate correctly.
The definition of contributory factors in the SI appears consistent with the findings.
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The definition of contributory factors in the SI appears consistent with the findings.
Even allowing for that quite wide definition, the basis for describing some of the factors as contributory is mere speculation without sufficient foundation in evidence.
There is an important difference between speculation and drawing a fair and reasonable inference from proved facts.
And also between drawing a fair and reasonable inference from proved facts and attempting to fit the evidence to a theory.
FL
Is it not the case that the cause of the accident was the inadvertent operation of the seat, and the cause of the fatality was the failure of the seat to operate correctly?
The SI was primarily considering the cause of the accident.
FL - agreed. e.g. point h. Self-medication. The text identifies it as a possible contributory factor, but the summary states that it was a contributory factor
The SI was primarily considering the cause of the accident.
FL - agreed. e.g. point h. Self-medication. The text identifies it as a possible contributory factor, but the summary states that it was a contributory factor
Last edited by Fox3WheresMyBanana; 9th Feb 2014 at 22:00.
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The SI was primarily considering the cause of the accident.
See Paragraph 2 and Annex A here: Convening Order
FL
F3,
The complication is that the fatality WAS the accident. The aircraft was only Cat 1. I was trying to get my head around the contributory/cause/aggravating thing a few pages back, but no-one really cleared it up. The board went for inadvertant ejection = cause, chute failure = aggravating factor. Having mulled it over I disagree with them because if the chute had worked, there would have been no "accident" in the strict sense of "major injury/Cat 4". So I think I would have gone for inadvertent ejection = contributory factor, chute failure = cause.
The complication is that the fatality WAS the accident. The aircraft was only Cat 1. I was trying to get my head around the contributory/cause/aggravating thing a few pages back, but no-one really cleared it up. The board went for inadvertant ejection = cause, chute failure = aggravating factor. Having mulled it over I disagree with them because if the chute had worked, there would have been no "accident" in the strict sense of "major injury/Cat 4". So I think I would have gone for inadvertent ejection = contributory factor, chute failure = cause.
lr:-
But if it had been a commanded ejection then the seat would still have malfunctioned and still resulted in a fatal accident. Easy Street is right, Flt Lt Cunningham died in an Airworthiness Related Accident because his seat parachute could not deploy. This was a compromised SI, like the others concerning Airworthiness Related Fatal Military Air Accidents that litter this Forum.
This has to stop. The MOD's finger prints are all over this SI, just as they are all over the disgraceful delaying of publication of the Report until after the Coroner's Inquest. Theirs was the only version of events readily available to the family and to the court. The MAAIB is dependent on the MAA (who were responsible for ensuring the airworthiness, or lack of it, of XX179), and the MAA is dependent on the MOD. Until that incestuous trio are entirely separated from each other the scandal of avoidable military airworthiness related air accidents will continue with its awful cost in blood and treasure.
Without the ejection - nothing happened !
This has to stop. The MOD's finger prints are all over this SI, just as they are all over the disgraceful delaying of publication of the Report until after the Coroner's Inquest. Theirs was the only version of events readily available to the family and to the court. The MAAIB is dependent on the MAA (who were responsible for ensuring the airworthiness, or lack of it, of XX179), and the MAA is dependent on the MOD. Until that incestuous trio are entirely separated from each other the scandal of avoidable military airworthiness related air accidents will continue with its awful cost in blood and treasure.
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Inshala, would take issue with your
From the report, it seems they didn't carry out their control checks in the recommended way either, as reference to the 1994 Valley accident to XX164 which claimed the life of one of my colleagues. (I was involved in a minor way with the recommendations after that BOI - I was tasked with re-writing the draft aircrew manual section for the new procedure). It's a small point, but brings up the fact that seemingly unrelated unofficial changes to SOPs can turn round and bite you eventually.
I'm fairly sure that when I was taught the workings of the seat back in 1986 our course was shown the 'position 2' of the handle and the fact that it was possible to place the pin in an unsafe way. I always remembered the teaching and i used to stick my head in the cockpit to check the pin was home correctly before standing on the seat. Did this corporate knowledge somehow get lost over the years?
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.
I'm fairly sure that when I was taught the workings of the seat back in 1986 our course was shown the 'position 2' of the handle and the fact that it was possible to place the pin in an unsafe way. I always remembered the teaching and i used to stick my head in the cockpit to check the pin was home correctly before standing on the seat. Did this corporate knowledge somehow get lost over the years?
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Easy
The SI adopted the following terminology -
Cause: The event that led directly to the accident.
Contributory: Factors that directly or indirectly made the accident more likely.
Aggravating: Factors that made the outcome of the accident worse.
Other: Factors that were none of the above, but could cause, contribute to or aggravate a future accident.
Observations: Factors that were not relevant to the accident but worthy of consideration to promote better working practices.
It is a pity that factors which in the opinion of the Panel did not lead directly to the accident, and did not directly or indirectly make the accident more likely, have attracted the most unpleasant and emotive comments in this thread. SOP for some PPRuNe contributors.
Transparency in such investigations is obviously desirable but it's a great pity that, in some instances, the integrity of individuals has been publicly impugned on the basis of what some might regard as at best flimsy evidence.
FL
I was trying to get my head around the contributory/cause/aggravating thing a few pages back, but no-one really cleared it up.
Cause: The event that led directly to the accident.
Contributory: Factors that directly or indirectly made the accident more likely.
Aggravating: Factors that made the outcome of the accident worse.
Other: Factors that were none of the above, but could cause, contribute to or aggravate a future accident.
Observations: Factors that were not relevant to the accident but worthy of consideration to promote better working practices.
It is a pity that factors which in the opinion of the Panel did not lead directly to the accident, and did not directly or indirectly make the accident more likely, have attracted the most unpleasant and emotive comments in this thread. SOP for some PPRuNe contributors.
Transparency in such investigations is obviously desirable but it's a great pity that, in some instances, the integrity of individuals has been publicly impugned on the basis of what some might regard as at best flimsy evidence.
FL