Go Back  PPRuNe Forums > Aircrew Forums > Military Aviation
Reload this Page >

Flt. Lt. Sean Cunningham inquest

Wikiposts
Search
Military Aviation A forum for the professionals who fly military hardware. Also for the backroom boys and girls who support the flying and maintain the equipment, and without whom nothing would ever leave the ground. All armies, navies and air forces of the world equally welcome here.

Flt. Lt. Sean Cunningham inquest

Thread Tools
 
Search this Thread
 
Old 10th Feb 2014, 19:12
  #521 (permalink)  
 
Join Date: Feb 2003
Location: uk
Posts: 3,225
Received 172 Likes on 65 Posts
Yes Vulcan, very well said. The concept of "ownership" ran through many components of airworthiness in MoD(PE) as well. Uniquely, we were named in contracts. It was scrapped (in our case) by the RAF Chief Engineer in 1993, the culmination of a quite conscious 2 year rundown period. Part of his "initiative" was that a directive was issued in 1991 that, henceforth, every civilian engineer was to be treated as subordinate to any administrator. A young Supply Manager, 3 grades and many years my junior, was appointed as my Line Manager. She was horrified. But others took great delight in their newly acquired airworthiness delegation. This led directly to the most serious issue raised in the C130 ART report (issued 14.1.98 by Inspector of Flight Safety). An astonishing period in my career which I've never forgotten, and made a point of retaining all correspondence.
tucumseh is offline  
Old 10th Feb 2014, 19:17
  #522 (permalink)  
 
Join Date: Jul 2006
Location: South of Old Warden
Age: 87
Posts: 1,375
Likes: 0
Received 1 Like on 1 Post
each aircraft was owned by a crew chief
I had a mate who was a crew chief on RAFAT back in the '70's. As I understood it, he was responsible for his one a/c and flew in it on any trip away from base.
All the crew chiefs were chief/techs/Sgt's
The USAF had crew chiefs (name on a/c) on many of it's a/c.
goudie is offline  
Old 10th Feb 2014, 19:31
  #523 (permalink)  
 
Join Date: Mar 2007
Location: Bristol Temple Meads
Posts: 869
Likes: 0
Received 0 Likes on 0 Posts
Running the accident events backwards, we get;

(1) Death of Flt. Lt Cunninghan, caused by
(2) Multiple injuries beyond the range of human tolerance, caused by
(3) Ground impact from 300 ft, caused by
(4) Failure of main chute to deploy, caused by
(5) Failure of shackle to release, caused by
(6) Over tightend bolt, caused by
(7) Inadequate technical information, caused by
(8) ???????

Where the hell does the seat pin fit in that sequence?

DV
Distant Voice is offline  
Old 10th Feb 2014, 19:35
  #524 (permalink)  
 
Join Date: Dec 2007
Location: Westnoreastsouth
Posts: 1,826
Received 33 Likes on 29 Posts
If the sph had not come out of its housing - and the sph pin had been fitted correctly - the seat would not have fired - and the chute would not have been required !
longer ron is online now  
Old 10th Feb 2014, 19:47
  #525 (permalink)  
 
Join Date: Apr 2003
Location: Omnipotent
Posts: 44
Likes: 0
Received 0 Likes on 0 Posts
Chug,

I wasn't being specific to the cause of the accident, I think we could debate causal factors, just as DV mentions - it depends where you start (or stop). I just wanted to comment that this is an entertaining thread on a very serious topic.

I also agree with Vulcan.
Growbag is offline  
Old 10th Feb 2014, 20:11
  #526 (permalink)  
 
Join Date: Dec 2007
Location: Westnoreastsouth
Posts: 1,826
Received 33 Likes on 29 Posts
I never said that the sph was cause of death...
I just agreed with the SI that the movement of the sph was the cause of the accident.
There is no doubt that the chute failure was cause of death but they are different definitions.
I also said that one could reasonably argue either way but it makes no difference to the outcome !
longer ron is online now  
Old 10th Feb 2014, 20:31
  #527 (permalink)  
 
Join Date: Apr 2009
Location: Wherever it is this month
Posts: 1,789
Received 75 Likes on 34 Posts
The bits about unit culture may well offend some who know or are connected with former RAFAT members. But there is simply no way that observations on cultural issues can be made with unequivocal, physical evidence, so it is inevitable that there will be a certain amount of gap-filling and inference by the Panel as they join together disparate items such as F700 procedures, briefing timelines, training records, IR currency etc. A SI is not bound by criminal standards of admissibility of evidence and the President would have formed an overall impression of the unit, for which he then had to select the best 'recordable' examples to illustrate in the report. He came to his view as an independent professional and evidently persuaded the Convening Authority that he had enough on which to base the comments. What interest could the President have in dragging the Reds through the mud for the sake of it? He was RN, so unlikely to be bitter in the way a failed selectee might have been, and there's no chance that the (light blue) DG MAA would have allowed his SI to be used as a platform for gratuitous inter-service sniping. In case my position is unclear, I think that the accident was made more likely by the pace at which routine business was being carried out. That makes unit culture a contributory factor, plain and simple.

I think I saw the phrase "tall poppy syndrome" used earlier, and frankly that sums it up. Too many display pilots have died and even killed others because their conduct and ability was considered beyond question by anyone outside the elite. Sometimes a "tall poppy" has to be cut down to size, and that's not bitterness, it's the sad lesson of at least 30 years of accidents. The very use of that phrase indicates that some consider the Reds to be above criticism. They're not.

Three points in closing:

One - I know that none of the current team were in place during the period which set the culture reported by the SI. That doesn't render the report irrelevant. 22 Gp would have been made aware of the Panel's concerns during the investigation, so it would be surprising if remedial action hadn't already been taken by the time of publication. The recorded findings are left to serve as another reminder to senior supervisors of things to watch for in future. No doubt they'll feature in discussion on flying supervisory courses.

Two - To those who protest at the team's portrayal. By virtue of your knowledge and connection to the (former) team, you have an emotional stake in their reputation. I trust the Panel's independent view more than I trust your protestations to the contrary, however well-informed or intentioned. For what it's worth, several individuals who I consider fit to hold a view are unsurprised by the findings.

Three - To Chug et al, do you really believe that today's VSOs would deliberately drag the good name of junior personnel in their premier PR and recruiting tool through the mud for the sole purpose of diverting attention from a finding that calls into question the conduct of some long-retired VSOs who now have zero influence over their careers? Especially when DG MAA was himself retiring, and when CAS is the self-same officer whose findings in the Mull board were turned over by the malign cabal? If anything, I would expect CAS to be hunting desperately for a chance to hang these old men out to dry.
Easy Street is offline  
Old 10th Feb 2014, 20:56
  #528 (permalink)  
 
Join Date: Feb 2012
Location: Far North of Watford
Age: 82
Posts: 535
Likes: 0
Received 0 Likes on 0 Posts
Easy Street

You were doing quite well. Until your second paragraph.

I think I saw the phrase "tall poppy syndrome" used earlier, and frankly that sums it up. Too many display pilots have died and even killed others because their conduct and ability was considered beyond question by anyone outside the elite. Sometimes a "tall poppy" has to be cut down to size, and that's not bitterness, it's the sad lesson of at least 30 years of accidents.
Because their conduct and ability was considered beyond question? That is why there have been accidents? Blimey. In that case for God's sake ground the whole Air Force. No, just the whole two winged master race. The only safe way to fly is remotely, with drones. Wait a mo, they've just given drone drivers wings! We're doomed!
Genstabler is offline  
Old 10th Feb 2014, 21:04
  #529 (permalink)  
 
Join Date: Apr 2009
Location: Wherever it is this month
Posts: 1,789
Received 75 Likes on 34 Posts
Well, I'll offer Bud Holland and his C17 copycat as 2 fatals straight off the bat, and the Linton Tucano non-fatal as examples of abject failure to cut down a tall poppy; that's without recourse to my FSC course notes. Light-touch supervision does not work and in display flying it kills (sorry Chug!)
Easy Street is offline  
Old 10th Feb 2014, 21:50
  #530 (permalink)  
 
Join Date: Feb 2012
Location: Far North of Watford
Age: 82
Posts: 535
Likes: 0
Received 0 Likes on 0 Posts
Easy Street

I understand your point about tall poppies. You are right. There will always be arrogant individuals at the top of their game who, if not reigned in, will exceed their limits and screw up.

Do you personally know the Reds? Have you met them? Watched them train, display and relax? If you have, then you will know that everything about their culture and ethos is based on the highest professional standards, safety and on TEAM work. That is why their pilot selection process, though unusual, works. They do not want or tolerate selfish individuals. They need to trust and be trusted. To honour their neighbour's airspace and to know that he will honour their's. That is their group think. Young civilian psychologists with no experience of, or exposure to, the Team can't get that. It goes against the stereotype. For that matter, a lot of guys who post on Pprune can't or won't get it either.

The SI comments on the Team's culture, ethos and selection procedures are garbage. A less arrogant, or more professional and well balanced group of young men I have yet to meet, and believe me I've met a lot.

That's me done. Believe what you like.
Genstabler is offline  
Old 10th Feb 2014, 21:53
  #531 (permalink)  
 
Join Date: Aug 2006
Location: West Sussex
Age: 82
Posts: 4,764
Received 227 Likes on 70 Posts
Not at all, Easy Street, I'm glad to see that my mantra has been noticed! Would that its message had taken similar hold within the MOD, which brings us to your challenge:-
Three - To Chug et al, do you really believe that today's VSOs would deliberately drag the good name of junior personnel in their premier PR and recruiting tool through the mud for the sole purpose of diverting attention from a finding that calls into question the conduct of some long-retired VSOs who now have zero influence over their careers? Especially when DG MAA was himself retiring, and when CAS is the self-same officer whose findings in the Mull board were turned over by the malign cabal?
Well, they weren't averse to dragging the good names of two deceased JOs through the mire for a decade and a half, and if you talk to some of them would do so for another decade and a half. My answer in short is yes, just as it was when asked if I was challenging the good word of honourable VSOs. I think you underestimate the grip that the Star Chamber has on its inmates. It has something of the Victorian Public School about it. One Star or below and you are expendable, two or more and you are fireproof. That's how it's worked to-date. Let us hope that the CAS is the one who changes it all and enables Regulation and Investigation to resume as they did in... well, Vulcan's days.
Having said that, I do not offer opinion about the state of the RAFAT, as I do not know. What I do know is that this accident was caused by lack of Airworthiness, and that the SI failed us and Flt Lt Cunningham by not saying that. We must ask ourselves why that was.

Last edited by Chugalug2; 10th Feb 2014 at 22:04.
Chugalug2 is online now  
Old 10th Feb 2014, 23:43
  #532 (permalink)  
 
Join Date: Jun 2011
Location: Lancashire
Age: 75
Posts: 29
Likes: 0
Received 0 Likes on 0 Posts
Incorrect Strap In

A lot has been said, but no one has yet pointed out that the first physical event in the train of events that led to the accident was the fact that on the previous flight the pilot was strapped in with the crotch strap through the SPH. If that had not happened, the SPH would never have got into the unsafe but stable “Position 2” and none of the rest would have happened.



As it happens, on the later flight the pin had legitimately been removed by the time the inadvertent ejection took place. The misplaced pin gave the pilot two opportunities to realise something was wrong and the maintainers a number of opportunities over the weekend to spot it also, but fundamentally it was the SPH being in Position 2 at the start of the later flight that led on to the fateful series of events.


Putting the crotch strap through the SPH is not something I would recommend on any aircraft. The so called MITL testing reported in the SI is very interesting. By some flook with a pilot of Cunningham’s proportions the seat appears not to self eject with one crotch strap thread through the SPH. With a pilot of different proportions or with the same seat in a different aircraft that may not be the case. With a different sized pilot it could well be the case that at some point during a flight with an incorrect crotch strap the pilot would experience an uncommanded ejection leaving an unpiloted aircraft in the middle of a formation with who knows what consequences. Of course in that circumstance (being above 50 kts) the shackle would probably have worked quite correctly.


I think some attention needs to be paid to this. We have heard of mods to the pin housing and to the shackle, but nothing that addresses this incorrect strap-in situation, the very first mistake in the sequence.


EG
Eminence Gris is offline  
Old 11th Feb 2014, 05:49
  #533 (permalink)  
 
Join Date: Dec 2007
Location: Westnoreastsouth
Posts: 1,826
Received 33 Likes on 29 Posts
You prob need to read the thread back a little further EG
longer ron is online now  
Old 11th Feb 2014, 07:16
  #534 (permalink)  
 
Join Date: Oct 2007
Location: York
Posts: 627
Received 23 Likes on 14 Posts
I don't see that it was ever mentioned that in 'normal' circumstances during bay servicing the drogue shackle bolt was only ever assembled (bolt fitted) before fitting to an open scissor shackle prior to it being closed and the BTRU cocked. If the bolt was incorrectly fastened it would be clear as the drogue shackle would not have fitted. Is it the case that the in-situ removal of the bolt was introduced to allow the crack detection on the seat beam to be carried out 'out of phase' with the seat servicing? If so I'm suprised the SI did not mention what assessment was done when it was introduced.
dctyke is offline  
Old 11th Feb 2014, 07:30
  #535 (permalink)  
 
Join Date: Feb 2003
Location: uk
Posts: 3,225
Received 172 Likes on 65 Posts
Easy Street


Superb post, but (to coin a phrase) you were doing so well until............

Three - To Chug et al, do you really believe that today's VSOs would deliberately drag the good name of junior personnel in their premier PR and recruiting tool through the mud for the sole purpose of diverting attention
I thought, to coin another phrase, that had been proven beyond any doubt whatsoever. While the SI report goes further than most others in overt criticism, it is what it DOES NOT say that is insidious. I firmly believe the members have been misled, by omission. If not, they have made themselves look stupid and withheld vital safety information.

After such a comprehensive investigation (within limits set by VSOs) is it not odd they present their 59 recommendations as revelations? While there is obviously a hint of systemic failures across MoD, you have to be pretty up on MoD procedures and practices to realise most of the recommendations are mandated policy, yet widely ignored in practice. The "organisation" they look at is the Red Arrows; not the MoD as a whole. That compartmentalisation POLICY is a proven killer.

It may be that the MAA is responsible for asking "Is there a wider applicability?" but it has demonstrated, again beyond any doubt, that it continues to trod the old path of protecting the current and past VSOs. An independent MAA would have no such qualms.

I'd like to think the MAA, in the background, is whispering in senior ears at wine and cheese dos "FFS, this has got to stop", but the secrecy they foster is not helping either SIs or MoD staffs who are weighed down by poor resources and illegal practices that have become policy.

Again, a simple fact; It remains an offence to refuse to obey an order to make a false declaration; but is not an offence to issue that order. The MAA was formally told of this, and the resultant fatalities, in the presence of Minister (AF) in 2011. DE&S policy branch have stated it in writing and briefed Minsters consistently, over many years. The Head of the Civil Service ruled so in December 2012. That ruling is not a good foundation. It eats at you and requires a strong person to do the right thing. In April 2003, PUS confirmed only one person in MoD thought it correct to follow the regulations. I suppose, then, the existence of the MAA is minor progress of sorts! But at huge cost.
tucumseh is offline  
Old 11th Feb 2014, 16:48
  #536 (permalink)  
 
Join Date: Mar 2007
Location: Bristol Temple Meads
Posts: 869
Likes: 0
Received 0 Likes on 0 Posts
I note, from the SI report, that after 130+ pages in the H-C report devoted to safety case and hazard log issues, the AES PT could not produce a safety case for the MK10 ejection seat, and the Hazard Log is flawed. A hazard log that should have referred to the possibilty of sticking shackle and the possibility to fit a safety pin incorrectly, IF a correct hazard identification and analysis had been carried out.

Come back Baber/Eagles, Quinetiq and BAE, all is forgiven. These guys got crucified for overlooking the fact that Dry Bay 7 did not have fire detection.

DV
Distant Voice is offline  
Old 11th Feb 2014, 18:24
  #537 (permalink)  
 
Join Date: Nov 2011
Location: Southern Europe
Posts: 5,335
Received 17 Likes on 6 Posts
tuc,

to be fair, I think the SI Report is one of the most thorough I've seen. Complete in terms of their remit, but not stepping beyond what they have powers to do. Without a lot more, probably unauthorized investigation, I can't see what further evidence they could present. They couldn't look at what you know, nor could they have used anything presented in other enquiries as evidence.

Whilst I fully understand your wider perspective on things, I'm afraid none of that was presentable evidence for them.

Also, not saying this has happened in this case, but the SI Report can sometimes be subject to change before it is agreed and published. My BOI Report was.
Courtney Mil is offline  
Old 11th Feb 2014, 18:52
  #538 (permalink)  
 
Join Date: Feb 2003
Location: uk
Posts: 3,225
Received 172 Likes on 65 Posts
CM

I have often asked the question whose job it is to reconcile differences between these reports and demonstrable fact. Also, who takes the next step when the SI/BoI stops abruptly and fails to ask the next logical question, which would reveal the truth. The answer is, the MAA. But they abrogate their responsibility.

As DV has said above, the Red Arrows SI report states a Safety Case report could not be found for the seat. (So what authority is there to fit it? Where is the audit trail back from the RTS?) Not that it was simply lost or mislaid, but there was an assumption that someone else had done the work. A Safety Critical system, and they rely on an assumption. Criminal.

On Nimrod, at least the IPT leader (Baber) recognised he should have a Safety Case, and let a contract. The fact he was meant to have inherited a continuous contract and valid Safety Case was conveniently overlooked in the rush to blame him. That the contract was managed poorly was an entirely different issue. For his alleged sins, MoD and the CPS considered the prosecution of he and others. They jumped back when the truth was revealed - that a policy had been issued that Safety Cases and updates would NOT be funded.

But now we have a quantum leap forward in gross dereliction of duty and making of false certification. Nimrod tried to update their old Safety Case; the seat IPT apparently didn't even bother asking if one existed in the first place, yet presumably certified it had one and that it was valid (otherwise the seat couldn't be presented to the aircraft IPTs for use).

Also, the Aircraft Design Authority (or whoever is tasked to prepare and maintain the Whole Aircraft Safety Case) is REQUIRED to verify the seat Safety Case exists and is valid, and subsume it within his Safety Case. How can the WASC be valid? How can the Hawk RTS be valid, or that of any other aircraft using this seat? This isn't some minor part of the aircraft, it is a Safety Critical System.

I've spoken before about the simple 3 link chain: Maintained Build Standard > Safety Case > RTS. In this case, the Build Standard was not maintained and there isn't a Safety Case to be found, which is far worse than Nimrod or even Chinook Mk2. Even on the latter, we have evidence of the aircraft project director advising senior staffs that the safety case was being compromised. On the seat, it seems no such warning could ever be forthcoming.

Common denominator? Who chopped the safety funding to offset the gross and conscious waste his department was perpetrating? Same old names, yet again. And, yet again, this fact is missing from an SI report. MoD/MAA know the failures, and the solution, but what have they done?

So, given this is in every way worse than Nimrod and Chinook, except in the number of deaths, can we expect a Haddon-Cave v2? And this time can we have someone who won't conceal the facts to protect certain retired VSOs?
tucumseh is offline  
Old 11th Feb 2014, 19:30
  #539 (permalink)  
 
Join Date: Aug 2006
Location: West Sussex
Age: 82
Posts: 4,764
Received 227 Likes on 70 Posts
The last two posts illustrate clearly that UK Military Air Safety is broken to the core. The very points that you make CM show just how the MAAIB is constrained by the MAA, which is constrained by the MOD.


Aircraft Accident Investigations should reveal the root cause of accidents. This one didn't come within a mile of that. Nothing of what tuc informs us was even hinted at. An aircraft escape system that lacked its own Safety Case? You couldn't make this stuff up.


The MOD nor any of its Service, Regulatory, or Investigative subsidiaries should be allowed to oversee Military Air Safety, for it is plainly not safe in their hands. Enough is enough, the MAA should be sistered to the CAA, and the MAAIB to the AAIB, with both of them led by civilian DGs. The words whelk stall come to mind!
Chugalug2 is online now  
Old 11th Feb 2014, 19:41
  #540 (permalink)  
 
Join Date: Apr 2005
Location: UK
Posts: 2,164
Received 47 Likes on 23 Posts
But now we have a quantum leap forward in gross dereliction of duty and making of false certification. Nimrod tried to update their old Safety Case; the seat IPT apparently didn't even bother asking if one existed in the first place, yet presumably certified it had one and that it was valid (otherwise the seat couldn't be presented to the aircraft IPTs for use).

Also, the Aircraft Design Authority (or whoever is tasked to prepare and maintain the Whole Aircraft Safety Case) is REQUIRED to verify the seat Safety Case exists and is valid, and subsume it within his Safety Case. How can the WASC be valid? How can the Hawk RTS be valid, or that of any other aircraft using this seat? This isn't some minor part of the aircraft, it is a Safety Critical System.
These are massive issues so worth repeating. To be clear, since the dawn of the MAA regulations the ODH is the named individual responsible for the Air System Safety Case - it is a 'shall' order and he is the owner and the manager of it. No escape (RA1205).

My burning question is how can it come to pass that a Safety Case is missing and yet the ODHs have declared the risks Tolerable and ALARP? On what basis can the ODH(s) make and sign their 6-monthly declarations if they have not scrutinised the non-existent SC?

I have seen no action taken against the ODH's for the 6-monthly rubber-stamping of Safety Cases that actually do not actually exist. It remains an act of Parliament that inaccurate certification is an imprisonable offence (sec 36).

http://www.maa.mod.uk/linkedfiles/re...ies/ra1205.pdf

Armed Forces Act 2006
Just This Once... is offline  


Contact Us - Archive - Advertising - Cookie Policy - Privacy Statement - Terms of Service

Copyright © 2024 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.