Flt. Lt. Sean Cunningham inquest
Apologies - I'd missed the low level of damage to the Hawk. I would therefore agree that the cause was the failure of the scissor shackle to operate correctly. The cause of which would appear to be miscommunication of some kind between MB & MoD
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Chugalug2
It would still have been an accident even if the seat had not malfunctioned and Flt Lt Cunningham had landed safely.
I wonder if you are confusing the cause of the accident with what caused it to become a fatal accident?
Since the family and the coroner had copies of the report, what's the problem?
The coroner heard evidence from some witnesses and would have seen witness statements made by others. He could also require anyone else to attend if he thought they might be able to help his inquiry.
Whose 'version of events' do you say should have been available to the coroner and wasn't?
The MOD allowed the Coroner - who is independent - to complete his investigation and publish his findings before publishing the MAA report which you claim is biased anyway.
Why is that disgraceful?
But if it had been a commanded ejection then the seat would still have malfunctioned and still resulted in a fatal accident.
I wonder if you are confusing the cause of the accident with what caused it to become a fatal accident?
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 coroner heard evidence from some witnesses and would have seen witness statements made by others. He could also require anyone else to attend if he thought they might be able to help his inquiry.
Whose 'version of events' do you say should have been available to the coroner and wasn't?
The MOD allowed the Coroner - who is independent - to complete his investigation and publish his findings before publishing the MAA report which you claim is biased anyway.
Why is that disgraceful?
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Overstress
Please explain what you are implying in this statement.
In my, albeit narrow, experience details of FRCs can be amended in the course of 20 years. Indeed you seem to have been involved in such an amendment yourself 20 years ago.
It's a small point, but brings up the fact that seemingly unrelated unofficial changes to SOPs can turn round and bite you eventually.
In my, albeit narrow, experience details of FRCs can be amended in the course of 20 years. Indeed you seem to have been involved in such an amendment yourself 20 years ago.
Bronx
If the chute had opened then there would have been no accident and hence no SI. Longstanding mil occurrence categorisation holds that an "accident" involves major injury (broadly, broken limb or worse) or Cat 4 damage to aircraft. If Sean had walked away then this would have been merely an "incident" and subject to nothing more than a unit inquiry, which would not be released by default (although FOI would probably see it released if someone asked the right question).
If the chute had opened then there would have been no accident and hence no SI. Longstanding mil occurrence categorisation holds that an "accident" involves major injury (broadly, broken limb or worse) or Cat 4 damage to aircraft. If Sean had walked away then this would have been merely an "incident" and subject to nothing more than a unit inquiry, which would not be released by default (although FOI would probably see it released if someone asked the right question).
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.
I would therefore agree that the cause was the failure of the scissor shackle to operate correctly. The cause of which would appear to be miscommunication of some kind between MB & MoD
But inbetween there was some poor engineering practice. On such an assembly the test has got to be freedom of movement, not torque or visible thread. However, I won't be too critical because there was no mention of what action the maintainers took, and whether or not it they were ignored - which is all too common.
But what the SI failed to mention was the systemic failures noted many times over a 20 year period. And, withheld from both SI and Coroner was the fact there is evidence of excellent communication coming from Martin Baker about the seat, increasing the chances the breakdown was within MoD (where it was practice NOT to communicate with Design Authorities because it was deemed a waste of money).
Just a couple of points that, if made available to the SI or Coroner, would have changed their direction significantly.
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Beagle, I fully agree with your post #479. The inadvertant (speculation) firing of the seat was an incident, caused by the apparent inabilty to fit the seat pan safety pin correctly. An incident that should have been prevented by whoever carried out the B/F on 4th November (No one mentioned in the SI?). To this incident the SI assigns 17 factors, but only 3 (or 4) to the real cause.
Cause of death; severe internal injuries caused by impact with the ground after falling 300 ft
Cause of accident; failure of chute to deploy
Cause of accident Sequence; inadvertent operation of firing handle.
DV
CORRECTION
B/F should read A/F
Cause of death; severe internal injuries caused by impact with the ground after falling 300 ft
Cause of accident; failure of chute to deploy
Cause of accident Sequence; inadvertent operation of firing handle.
DV
CORRECTION
B/F should read A/F
Last edited by Distant Voice; 10th Feb 2014 at 09:38.
Bronx:-
Let's dot the i's and cross the t's here. In previous fatal accidents the BoI was published ahead of a coroner's inquest. This enabled the family and the coroner to get input from other than the MOD alone. It was then often the family that became the focus of a campaign to right an injustice, insist that aircraft receive the protection that their brother's hadn't, or to simply reveal MOD lies for what they were. The mandarins have obviously decided that this is unacceptable from their point of view, and so have limited publication to non aviation professionals only, ie the family, its lawyers, and the coroner.
As usual this SI points the finger at the first person on the scene of the accident, whereas the genesis of this accident began in 1988 when RAF VSOs began deliberately to destroy the system that had assured UK Military Airworthiness Provision. That system remains broken and will go on being broken until the MAA faces up to cause and effect, and breaks away from the MOD so that it is free to publish and be damned. Ditto all that, especially in regard to this accident, with the MAAIB.
Rather than stemming the canker of unairworthiness that infects UK Military Aviation, the MAA is presiding over the spread of it from fleet to fleet. The MAA is part of the problem and not the cure. It needs to take urgent action as above, or the 63 deaths noted in this forum will simply go on growing inexorably.
Since the family and the coroner had copies of the report, what's the problem?
The coroner heard evidence from some witnesses and would have seen witness statements made by others. He could also require anyone else to attend if he thought they might be able to help his inquiry.
Whose 'version of events' do you say should have been available to the coroner and wasn't?
The MOD allowed the Coroner - who is independent - to complete his investigation and publish his findings before publishing the MAA report which you claim is biased anyway.
Why is that disgraceful?
The coroner heard evidence from some witnesses and would have seen witness statements made by others. He could also require anyone else to attend if he thought they might be able to help his inquiry.
Whose 'version of events' do you say should have been available to the coroner and wasn't?
The MOD allowed the Coroner - who is independent - to complete his investigation and publish his findings before publishing the MAA report which you claim is biased anyway.
Why is that disgraceful?
As usual this SI points the finger at the first person on the scene of the accident, whereas the genesis of this accident began in 1988 when RAF VSOs began deliberately to destroy the system that had assured UK Military Airworthiness Provision. That system remains broken and will go on being broken until the MAA faces up to cause and effect, and breaks away from the MOD so that it is free to publish and be damned. Ditto all that, especially in regard to this accident, with the MAAIB.
Rather than stemming the canker of unairworthiness that infects UK Military Aviation, the MAA is presiding over the spread of it from fleet to fleet. The MAA is part of the problem and not the cure. It needs to take urgent action as above, or the 63 deaths noted in this forum will simply go on growing inexorably.
Accident vs Incident
I am just confused by the use of the 'accident' word. It seems it CAN be used to take away responsibility for what can be preventable.
Surely there is someone somewhere who is responsible for system failures. It seems in all walks of life, people want the pay and prestige of having responsibility, but when push comes to shove it is never their fault, always an accident.
Sorry.
Surely there is someone somewhere who is responsible for system failures. It seems in all walks of life, people want the pay and prestige of having responsibility, but when push comes to shove it is never their fault, always an accident.
Sorry.
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The mandarins have obviously decided that this is unacceptable from their point of view, and so have limited publication to non aviation professionals only, ie the family, its lawyers, and the coroner.
DV
An incident that should have been prevented by whoever carried out the B/F on 4th November (No one mentioned in the SI?)
One could argue either way about the cause of the accident,but it is different to the cause of death !
Whilst the failure of the chute to open was the cause of death,this would not have happened if the seat had not fired in the first place - so it would be fair to say that the seat firing was the cause !
There still seems to be resistance to accepting the circumstances causing the seat to fire...
I cannot comment on the wider accusations about VSO's etc but I can say that the technical investigation of this tragic accident was very in depth and of an extremely high standard...it was always going to be a difficult one !!
Whilst the failure of the chute to open was the cause of death,this would not have happened if the seat had not fired in the first place - so it would be fair to say that the seat firing was the cause !
There still seems to be resistance to accepting the circumstances causing the seat to fire...
I cannot comment on the wider accusations about VSO's etc but I can say that the technical investigation of this tragic accident was very in depth and of an extremely high standard...it was always going to be a difficult one !!
longer ron,
Here is the MAA's own Master Glossary. You will see that there was no accident until Flt Lt Cunningham was killed, which as you say was caused by his chute failing to open. The SI itself stated that the aircraft only received Cat1 damage, as has already been pointed out. It would have had to receive Cat4 or 5 damage for it to have been the subject of an accident :-
http://www.maa.mod.uk/linkedfiles/regulation/maa02.pdf
This is not some arcane argument about angels and heads of pins. Rather it is proof, if any were needed, that SIs are still subject to outside influences and cannot be relied upon to do their job. Their job should be to determine accident causes in order to prevent future occurrences. Rather it seems it is to go on protecting VSO backsides at the cost of more junior ones.
Here is the MAA's own Master Glossary. You will see that there was no accident until Flt Lt Cunningham was killed, which as you say was caused by his chute failing to open. The SI itself stated that the aircraft only received Cat1 damage, as has already been pointed out. It would have had to receive Cat4 or 5 damage for it to have been the subject of an accident :-
http://www.maa.mod.uk/linkedfiles/regulation/maa02.pdf
This is not some arcane argument about angels and heads of pins. Rather it is proof, if any were needed, that SIs are still subject to outside influences and cannot be relied upon to do their job. Their job should be to determine accident causes in order to prevent future occurrences. Rather it seems it is to go on protecting VSO backsides at the cost of more junior ones.
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The pin is checked by everybody who enters/works in cockpit,it is only 'fitted' by the pilot unless on deeper maintenance than first line
If it doesn't say that, what does it say?
DV
NOTE
My post #489 should have said A/F not B/F
Chug
I am not bothered either way...as I said previously - one could argue either way about and it makes no practical difference anyway !
This accident was highly unusual in that the aircraft was only slightly damaged just yards from the operators hangar.
This alone makes the cause/occurrence unusual but I would not read anything into that particular wording unless one wants to be pedantic !
I am not bothered either way...as I said previously - one could argue either way about and it makes no practical difference anyway !
This accident was highly unusual in that the aircraft was only slightly damaged just yards from the operators hangar.
This alone makes the cause/occurrence unusual but I would not read anything into that particular wording unless one wants to be pedantic !
DV
I understand what you are saying,I was just saying that it is a shared responsibility,safety check wise the last person who enters the cockpit has the responsibility to check the pin and in this case that would not have been the tradesman !
I have seen quite a few people on here who have never missed checks/made mistakes...to err is to be human - yes it is a basic check but with a Hawk front seat one has to be aware that viewed from above it is a subtle defect,one has to move ones head down and fwd to see the handle/pin relationship clearly,which I am sure we all do now.
rgds LR
I understand what you are saying,I was just saying that it is a shared responsibility,safety check wise the last person who enters the cockpit has the responsibility to check the pin and in this case that would not have been the tradesman !
I have seen quite a few people on here who have never missed checks/made mistakes...to err is to be human - yes it is a basic check but with a Hawk front seat one has to be aware that viewed from above it is a subtle defect,one has to move ones head down and fwd to see the handle/pin relationship clearly,which I am sure we all do now.
rgds LR
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Chugalug2
You haven't done that, you;ve just repeated your broad brush conspiracy theories.
The SI report was given to the family and the coroner ahead of the coroner's inquest. This enabled the family and the coroner to get input from other than the MOD alone.
The Coroner did that.
The family had a QC advising them and he questioned witnesses on their behalf.
The family could have asked the coroner to hear input from other witnesses including experts if they'd wanted to.
From the Telegraph report of the inquest:
You still haven't answered my question - Whose 'version of events' (your expression) do you say should have been available to the coroner and wasn't?
Let's dot the i's and cross the t's here.
In previous fatal accidents the BoI was published ahead of a coroner's inquest. This enabled the family and the coroner to get input from other than the MOD alone.
The Coroner did that.
The family had a QC advising them and he questioned witnesses on their behalf.
The family could have asked the coroner to hear input from other witnesses including experts if they'd wanted to.
From the Telegraph report of the inquest:
The team leader at the time, Sqd Ldr Jim Turner, said he was frustrated by a lack of support and a shortage of around 20 engineers.
He said: “We were telling them repeatedly we needed more personnel and more aircraft. The sense that I had in the short time I was boss was that we needed more stuff. We needed more manpower. We needed a little bit more.”
He said when he took over the job he was surprised to see some of the engineers were “very young and very inexperienced”.
He said: “We were telling them repeatedly we needed more personnel and more aircraft. The sense that I had in the short time I was boss was that we needed more stuff. We needed more manpower. We needed a little bit more.”
He said when he took over the job he was surprised to see some of the engineers were “very young and very inexperienced”.
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DV
Did any ground tradesman sign for the A/F, and did that A/F, iaw bla bla bla, require a seat check?
The SI did not go into such detail, but I can guarantee that tradesmen will have signed for checking the seat pins.
However, Flt Lt Cunningham himself signed in the aircraft after the 4th Nov flight and this rather trumps everything. Unless of course the Reds have some arrangement which wouldn't surprise me.
Did any ground tradesman sign for the A/F, and did that A/F, iaw bla bla bla, require a seat check?
The SI did not go into such detail, but I can guarantee that tradesmen will have signed for checking the seat pins.
However, Flt Lt Cunningham himself signed in the aircraft after the 4th Nov flight and this rather trumps everything. Unless of course the Reds have some arrangement which wouldn't surprise me.
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surprised to see some of the engineers were “very young and very inexperienced”.
I'm pretty certain that at one time, engineers had to have completed at least one tour elsewhere and been 'above average', before being considered for the RAFAT.
Same applied for postings to 'The Queen's Flight'.
Bronx, the discussion on this thread alone shows what can become apparent once access to a published SI report is possible by professionals (and I count all those who have posted here in that manner, lest you think I am claiming some unique insight). The suggestion that showing this SI alone to non-professionals prompts them to ask informed questions about it is disingenuous. They are told that the cause of this accident was the (inadvertent) initiation of the firing sequence, and why should they not accept that? Yet I am not alone on this thread in claiming that to be plain wrong, and that the cause was the failure of the scissor shackle to open, allowing main chute deployment. That is just one example of the version of events differing to that offered to the family and the coroner.
If you don't know what questions to ask then you don't ask them. If you don't know what version of events has been published then you cannot dispute them. Those are the i's and t's that were not dotted and crossed at the inquest. Why? Because publication was withheld for that very reason.
Previous Coroners have heavily criticised the MOD for the state of its aircraft. By delaying general publication of the SI that criticism was curtailed. We cannot rely on the MAAIB to determine the cause of airworthiness related military air accidents, and have had to rely on an 800 year old institution to point out our airworthiness shortcomings. Now that window has been effectively closed by the MOD. In doing so it reveals its disinterest in maintaining Air Safety, and I encourage others to ask themselves why should that be?
If you don't know what questions to ask then you don't ask them. If you don't know what version of events has been published then you cannot dispute them. Those are the i's and t's that were not dotted and crossed at the inquest. Why? Because publication was withheld for that very reason.
Previous Coroners have heavily criticised the MOD for the state of its aircraft. By delaying general publication of the SI that criticism was curtailed. We cannot rely on the MAAIB to determine the cause of airworthiness related military air accidents, and have had to rely on an 800 year old institution to point out our airworthiness shortcomings. Now that window has been effectively closed by the MOD. In doing so it reveals its disinterest in maintaining Air Safety, and I encourage others to ask themselves why should that be?