Flt. Lt. Sean Cunningham inquest
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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.
This may seem to be detail, but it is detail that the SI should have addressed. It was one of the first questions I asked myself.
DV
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DV, whilst I take your point regarding the AF and the same might be true of the AF, as well as the check by the pilot before entering the cockpit. Is the suggestion that the groundcrew who signed for that AF should be held to account? Given that the application of Just Culture requires a substitution test, which in this case was passed by a number of people in the process who missed the incorrect location of the pin I see the focus should therefore be on how to prevent the recurrence of this problem.
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Okay DV,
War story time. On many Mk's of Canberra there is a fire bottle in the rear fuselage accessed via the back hatch, lots of dzus fasteners to undo just to check a fire bottle hasn't gone off. Some engineers didn't bother checking it. One day, an engineer did check it and found the fire bottle to be discharged. On investigation, it was discovered that the fire bottle head had been wired incorrectly and that it had fired the first time power had been applied to the aircraft. OC 100 Sqn wanted every single engineer who had serviced the aircraft to be Tech Charged. The Flt Sgt began proceedings and quickly discovered that OC 100 Sqn had himself taken the aircraft on a land away and was as slack as his airmen. Case closed, swept under the carpet, due to Trumpage.
War story time. On many Mk's of Canberra there is a fire bottle in the rear fuselage accessed via the back hatch, lots of dzus fasteners to undo just to check a fire bottle hasn't gone off. Some engineers didn't bother checking it. One day, an engineer did check it and found the fire bottle to be discharged. On investigation, it was discovered that the fire bottle head had been wired incorrectly and that it had fired the first time power had been applied to the aircraft. OC 100 Sqn wanted every single engineer who had serviced the aircraft to be Tech Charged. The Flt Sgt began proceedings and quickly discovered that OC 100 Sqn had himself taken the aircraft on a land away and was as slack as his airmen. Case closed, swept under the carpet, due to Trumpage.
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Checks of the seat pin by Flt Lt Cunningham and others would appear to have been superficial. The seat pin was never checked properly and the excuse that it is difficult to see is risable. Claiming your sim hours when you have not done the time is just another indication that standards were not adhered to or were non existant.
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Vulcan
This is your second post impuning the integrity and professionalism of RAFAT based on a flawed report. If you really want to open your mind before again engaging finger, please read posts 453 and 462, which appear to be from someone who seems to know what he's talking about.
This is your second post impuning the integrity and professionalism of RAFAT based on a flawed report. If you really want to open your mind before again engaging finger, please read posts 453 and 462, which appear to be from someone who seems to know what he's talking about.
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Sir Peter, I enjoyed your war story but not aware of the incident. I will add my own that is slightly relevant to this thread:
A young dragartist under instruction. Canberra Servicing Flt, Wyton, early 80s. Asked to assist in an post maintenance AF/BF. I had completed a number of practical tasks and been briefed on seat pins. The aircraft was a B2 with the banner towing hook at the back of the bomb bay. Cpl Scoggins agreed to read and I would carry out the check. A spring loaded pin on the undercarriage door. "check operation". I looked over the door and could not relate to the words. Nor Could Cpl Scoggins. It took a while to work it out. A very simple check pushing the pin against the spring with the palm of ones hand. it appeared that Cpl Scoggins had been signing for having completed these checks for years without knowing what he was signing for!
One of those I learned about maintaining aircraft from that moments.
An older dragartist on det at a top secret airbase in Cornwall. Goes into the HAS to be greeted by S/Sgt (lets call him Pike) Pike had been done for signing for things he had not completed. I thought he had been sent to Colchester for correctional training. "dragartist, this kit you are responsible for has bits missing" Replies "Well Pike how TF am I supposed to know. you mean you dragged me 350 miles to tell me. Why can't you just fill in a F765 to get the books amended or a F760 if the kit is faulty? Pike replies- "wots one of them?" A few months later Pike gets promoted to WO2. I think he even went on to STANEVAL. His correctional training must have worked!
A young dragartist under instruction. Canberra Servicing Flt, Wyton, early 80s. Asked to assist in an post maintenance AF/BF. I had completed a number of practical tasks and been briefed on seat pins. The aircraft was a B2 with the banner towing hook at the back of the bomb bay. Cpl Scoggins agreed to read and I would carry out the check. A spring loaded pin on the undercarriage door. "check operation". I looked over the door and could not relate to the words. Nor Could Cpl Scoggins. It took a while to work it out. A very simple check pushing the pin against the spring with the palm of ones hand. it appeared that Cpl Scoggins had been signing for having completed these checks for years without knowing what he was signing for!
One of those I learned about maintaining aircraft from that moments.
An older dragartist on det at a top secret airbase in Cornwall. Goes into the HAS to be greeted by S/Sgt (lets call him Pike) Pike had been done for signing for things he had not completed. I thought he had been sent to Colchester for correctional training. "dragartist, this kit you are responsible for has bits missing" Replies "Well Pike how TF am I supposed to know. you mean you dragged me 350 miles to tell me. Why can't you just fill in a F765 to get the books amended or a F760 if the kit is faulty? Pike replies- "wots one of them?" A few months later Pike gets promoted to WO2. I think he even went on to STANEVAL. His correctional training must have worked!
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The SI report states;
"On 7th Nov 11 After Flight (A/F) and Before Flight (B/F) servicing was conducted on XX177 in preparation for flight which included making the seat safe for parking."
Now we can talk about just culture etc., but clearly whoever signed for the job did not make the seat safe for parking. What surprises me is that this failure gets no mention in the SI. If it is a difficult task to perform on Hawk aircraft, why over the many years of operation has this fact has not been brought to attention of higher authority? Or has it?
I assume that an A/F was carried out on 4th Nov, and the seat made safe for servicing. Again, no mention.
DV
"On 7th Nov 11 After Flight (A/F) and Before Flight (B/F) servicing was conducted on XX177 in preparation for flight which included making the seat safe for parking."
Now we can talk about just culture etc., but clearly whoever signed for the job did not make the seat safe for parking. What surprises me is that this failure gets no mention in the SI. If it is a difficult task to perform on Hawk aircraft, why over the many years of operation has this fact has not been brought to attention of higher authority? Or has it?
I assume that an A/F was carried out on 4th Nov, and the seat made safe for servicing. Again, no mention.
DV
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DV, I think it is safe to say that this point has been received loud and clear by those in authority. having followed this thread it talks about two modifications being introduced: one to fit a shoulder bolt to prevent the shackle getting stuck in the scissors. A second mod to revise the pin assembly. I would have expected both these points to have been covered off by a SFI or whatever they call them these days, to check for free movement in the shackle and also ensure the pins are correctly installed. I bet everyone getting in a jet since the incident has been particular about these checks. I think the article in the newspapers and bbc refer to these mods being rolled out by April this year.
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CM
I have read the posts #453 and #462 and bow to the author who has greater and more up to date knowledge than I who departed from the service decades ago. My experience since had been with large organisations both as a salesman of high value equipment and later on as a UK sales manager. The failure to spot the misplaced pin, is at ground level the responsibility of those who entered the cockpit. They were all going about their tasks based on the culture and ethos that existed in the RAFAT at that time. Based on post #453 we hear that sim time "counts for nothing" which begs the question why is it logged, is this just a box ticking exercise ? Many organisations spend time and energy creating job descriptions and assesment systems by which they check the performance and quality of the individual. None of this will work without on the job training and education and the total support and commitment from the top executives. In reality it requires us not just to talk the talk but to walk the walk. It may be that senior echelons in the RAF are blind to how their decisions impact those who work on the front line and need less talk and more walking.
I have read the posts #453 and #462 and bow to the author who has greater and more up to date knowledge than I who departed from the service decades ago. My experience since had been with large organisations both as a salesman of high value equipment and later on as a UK sales manager. The failure to spot the misplaced pin, is at ground level the responsibility of those who entered the cockpit. They were all going about their tasks based on the culture and ethos that existed in the RAFAT at that time. Based on post #453 we hear that sim time "counts for nothing" which begs the question why is it logged, is this just a box ticking exercise ? Many organisations spend time and energy creating job descriptions and assesment systems by which they check the performance and quality of the individual. None of this will work without on the job training and education and the total support and commitment from the top executives. In reality it requires us not just to talk the talk but to walk the walk. It may be that senior echelons in the RAF are blind to how their decisions impact those who work on the front line and need less talk and more walking.
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Vulcan
I think he explains what he means quite clearly in that paragraph. Meanwhile you persist in criticising the culture and ethos of the Team at the time, once more implying a lack of integrity and professionalism. What is your motivation and what experience do you base that criticism on?
sim time "counts for nothing" which begs the question why is it logged, is this just a box ticking exercise ?
Meanwhile you persist in criticising the culture and ethos of the Team at the time, once more implying a lack of integrity and professionalism. What is your motivation and what experience do you base that criticism on?
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I'm enjoying reading this thread, which is the epitome of PPRuNe, where conjecture and opinion is interspersed with entrenched views and a smattering of mudslinging...particularly where individuals want to give an alternative view of events to the findings of an SI. I'm sure that previous posters who want to preserve the reputation of the Reds mean well, and I am sure they believe what they say, but the Panel of an SI don't just base their findings on 'a feeling' or cobbled together evidence - they make a judgement using the experience that they have and the reason they were chosen to do the job in the first place.
The Panel also know that the report will be scrutinised by lawyers, next of kin, military stakeholders and eventually the public and media, therefore the findings have enough basis for being included "on the balance of evidence". If the family or the RAFAT QCs had been instructed that findings were baseless, they had every chance at the Inquest to raise them.
I know for a fact that understanding the detailed questioning which results from an SI, nothing would be included if the Panel could not support the findings with evidence. The difference of opinion, I am sure, is the interpretation of that evidence and often the vagaries of regulation or policy.
We are all very proud of the Reds, but there were practices taking place that were not policy compliant, nor were they justifiable. The fact that the recommendations were supported and implemented means the report did its job, after all it is an air safety document attempting to ensure that such tragedies do not happen again.
The Panel also know that the report will be scrutinised by lawyers, next of kin, military stakeholders and eventually the public and media, therefore the findings have enough basis for being included "on the balance of evidence". If the family or the RAFAT QCs had been instructed that findings were baseless, they had every chance at the Inquest to raise them.
I know for a fact that understanding the detailed questioning which results from an SI, nothing would be included if the Panel could not support the findings with evidence. The difference of opinion, I am sure, is the interpretation of that evidence and often the vagaries of regulation or policy.
We are all very proud of the Reds, but there were practices taking place that were not policy compliant, nor were they justifiable. The fact that the recommendations were supported and implemented means the report did its job, after all it is an air safety document attempting to ensure that such tragedies do not happen again.
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DV
1.3.6 refers
PS. The SI author can't spell "Hangar" so the whole thing is flawed
I assume that an A/F was carried out on 4th Nov, and the seat made safe for servicing. Again, no mention.
PS. The SI author can't spell "Hangar" so the whole thing is flawed
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Growbag
What you say is mostly true in reference to the technical findings. The forensic investigation of the likely cause of the initiation and of the subsequent failure of the shackle release are compelling and impressive. It was carried out, not by the panel, but by technical experts (Royal Navy I believe) at the behest of the Board. However, though evidence based and therefore credible, their conclusions are still only theory, not fact.
However, I am afraid I have good reason to believe that the part of the report that deals with culture and ethos in RAFAT, and which was written by members of the Panel, is not evidence based and is not credible. It is theory, written by civilian psychologists with no actual experience of the military, let alone of the RAFAT, and those theories have been represented as fact.
Please reread 453 and 462. If those of you, like Dervish and Growbag, believe that, despite evidence to the contrary, the SI speaks ex cathedris and must be taken as absolute gospel, then there will be no pursuading you.
My heart goes out to Sean's family, and to Eggman's. It also goes out to their friends and colleagues who watched them both die and are now having their own character and professionalism besmirched.
but the Panel of an SI don't just base their findings on 'a feeling' or cobbled together evidence - they make a judgement using the experience that they have and the reason they were chosen to do the job in the first place.
However, I am afraid I have good reason to believe that the part of the report that deals with culture and ethos in RAFAT, and which was written by members of the Panel, is not evidence based and is not credible. It is theory, written by civilian psychologists with no actual experience of the military, let alone of the RAFAT, and those theories have been represented as fact.
Please reread 453 and 462. If those of you, like Dervish and Growbag, believe that, despite evidence to the contrary, the SI speaks ex cathedris and must be taken as absolute gospel, then there will be no pursuading you.
My heart goes out to Sean's family, and to Eggman's. It also goes out to their friends and colleagues who watched them both die and are now having their own character and professionalism besmirched.
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Genstabler
My experience is dated; I flew V-Force in the '70's for 8 years and took redundancy in the clear out by Wilson's government in '76. I voluntered to leave as my experience as a green shield stamp (graduate) officer lead me to conclude that the RAF viewed me and other junior officers as resources to clean windows when the upper echelons visited and carry out any other menial tasks without question. I did not get a BSc in physics to clean windows. I did fly in an era when the RAF had the best engineering support you could wish for; each aircraft was owned by a crew chief, nobody other than qualified tradesmen touched the plane. Confidence in their skills and integrity was total. If only the RAFAT had the support I enjoyed all those years ago, perhaps we would not be posting on this today.
My experience is dated; I flew V-Force in the '70's for 8 years and took redundancy in the clear out by Wilson's government in '76. I voluntered to leave as my experience as a green shield stamp (graduate) officer lead me to conclude that the RAF viewed me and other junior officers as resources to clean windows when the upper echelons visited and carry out any other menial tasks without question. I did not get a BSc in physics to clean windows. I did fly in an era when the RAF had the best engineering support you could wish for; each aircraft was owned by a crew chief, nobody other than qualified tradesmen touched the plane. Confidence in their skills and integrity was total. If only the RAFAT had the support I enjoyed all those years ago, perhaps we would not be posting on this today.
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Genstabler, you seem to mix 'fact', 'evidence', 'credible' and 'theory' to your benefit. I too made the same mistake in my earlier post, as there are facts (the shackle was over-tightened) and considerations based upon facts presented (culture based upon observation/interview). I defer that findings regarding culture will be less factually based (there will never be any perfect basis for such observations) but they do not detract from the conclusion of A Panel. I emphasise A Panel because another Panel may have come to different conclusions, may have highlighted different cultural observations, and may have placed different emphasis on different findings.
This doesn't mean that they are wrong, it means that the professional opinion of a panel of independent military specialists came to the conclusions published, when presented with the evidence and facts that are annotated in the right hand side column of the report. I'd like to believe that the Panel asked the same questions that we all have asked in earlier posts, and in our own conversations with colleagues, as without the balanced questioning, how can any independent panel come up with a report to make positive change?
Just ask yourself, in the interviews with the pilots, did they ask, "did you do the full time in the simulator that you logged, or did you share it with another pilot?" If there was a reasonable policy answer to that, then there would have been absolutely no reason to include it in the report. This goes for all the other unpalatable 'culture' sections or mentions of self-medication.
Every unit has tough times, and a SI report is not a vehicle to besmirch reputations, it is a means to raise air safety. I, like every thinking individual, do not accept what is presented without questioning its validity and credibility. What I attempt to do is see through the uncomfortable reading and believe that the pilots did not get up in the morning thinking they were going to be unprofessional, and instead that anyone who wants to be the best in the world, should take any offer of positive criticism and grasp the opportunity to have a long look at established cultures to check to see THEIR validity.
These are terrible events, and often they are the catalyst for much soul searching and change. I would be surprised if the team wouldn't want to be beyond such comment in the future, surely they would want to have a culture to be proud of?
This doesn't mean that they are wrong, it means that the professional opinion of a panel of independent military specialists came to the conclusions published, when presented with the evidence and facts that are annotated in the right hand side column of the report. I'd like to believe that the Panel asked the same questions that we all have asked in earlier posts, and in our own conversations with colleagues, as without the balanced questioning, how can any independent panel come up with a report to make positive change?
Just ask yourself, in the interviews with the pilots, did they ask, "did you do the full time in the simulator that you logged, or did you share it with another pilot?" If there was a reasonable policy answer to that, then there would have been absolutely no reason to include it in the report. This goes for all the other unpalatable 'culture' sections or mentions of self-medication.
Every unit has tough times, and a SI report is not a vehicle to besmirch reputations, it is a means to raise air safety. I, like every thinking individual, do not accept what is presented without questioning its validity and credibility. What I attempt to do is see through the uncomfortable reading and believe that the pilots did not get up in the morning thinking they were going to be unprofessional, and instead that anyone who wants to be the best in the world, should take any offer of positive criticism and grasp the opportunity to have a long look at established cultures to check to see THEIR validity.
These are terrible events, and often they are the catalyst for much soul searching and change. I would be surprised if the team wouldn't want to be beyond such comment in the future, surely they would want to have a culture to be proud of?
LR. Did any ground tradesman sign for the A/F, and did that A/F, iaw bla bla bla, require a seat check?
It is easy to be wise after the event - this accident has re highlighted a previous problem vis a vis the possibility of fitting the pin through a sph which is out of its housing.
It is a shared responsibility,ground tradesmen never touch that pin - it is a visual check !
As I said previously - it is easy to be wise after the event... I am still seeing quite a few people who have never made a mistake or missed a check in their lives !
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I did fly in an era when the RAF had the best engineering support you could wish for; each aircraft was owned by a crew chief, nobody other than qualified tradesmen touched the plane. Confidence in their skills and integrity was total. If only the RAFAT had the support I enjoyed all those years ago, perhaps we would not be posting on this today.
Gs:-
Amen to that.
Growbag:-
So are you saying that the SI was right in attributing the cause of this accident as it did, and if so why?
I think Vulcan has hit the nail squarely on the head.
Growbag:-
the epitome of PPRuNe, where conjecture and opinion is interspersed with entrenched views and a smattering of mudslinging...particularly where individuals want to give an alternative view of events to the findings of an SI.