Flt. Lt. Sean Cunningham inquest
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Wot no safety case
DV, I too was taken aback reading that there was no safety case report. there must have been something. I read the term e-Cassandra (I think, or did I imagine it?)
I would like to ask what happened to the Cassandra Hazard log I helped the EA in the then S&AD IPT to put together. It was back in the early naughties. It may not have been for that particular seat. I had no knowledge of the seat mechanics but did have experience of Cassandra from a previous life.
Would it have made any difference to the SI? I'm not that sure. What I do know is that had the hazardous condition of the shackle been on it then someone would have had to have made an ALARP statement.
You mention George and others in relation to Haddon Cave. I wonder if those responsible in the AES will suffer a similar fate.
Tuc mentioned the HEART report of the 90s in an earlier post. I was still wrestling with some of those recommendations up to the day I retired.
I would like to ask what happened to the Cassandra Hazard log I helped the EA in the then S&AD IPT to put together. It was back in the early naughties. It may not have been for that particular seat. I had no knowledge of the seat mechanics but did have experience of Cassandra from a previous life.
Would it have made any difference to the SI? I'm not that sure. What I do know is that had the hazardous condition of the shackle been on it then someone would have had to have made an ALARP statement.
You mention George and others in relation to Haddon Cave. I wonder if those responsible in the AES will suffer a similar fate.
Tuc mentioned the HEART report of the 90s in an earlier post. I was still wrestling with some of those recommendations up to the day I retired.
I would wager that the ODHs have been signing a 6-monthly declaration only on their platform safety cases, which now exist. Whether their advisers would inform them that one of the components (the seat) was supposed to have its own "subsidiary" safety case I have no idea. Since fast jets tend to have little in the way of resilience or redundancy, the availability of an ejection option tends to feature highly in platform risk mitigation measures.... ooops.
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Money no Object
Just seen the headlines re the floods. I wonder if money is being thrown at filling the gaps described above. I recall when we had a freeze on external recruiting the only exemption was for safety related posts. This was at a time when hundreds were volunteering to leave. Questions were being asked at the PAC over the use of consultants in October 2011. I know a couple who left on Friday and started back on Monday as Consultants doing safety jobs. Oh funny Al R started a thread earlier today on the Annual Report where the recurring theme of use of consultants prevails. This time those with financial skills. Nothing new there then.
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A simple feeler gauge check for gap between the mechanism, bolt, nut etc, is all that is required on the scissor shackle.
It seems to me, first year student stuff, quite obvious to anyone really & no, it's not hindsight, just completely obvious stuff.
I'm still somewhat bemused at the layer upon layer of technical administration, that did not realise such a simple thing.
It seems to me, first year student stuff, quite obvious to anyone really & no, it's not hindsight, just completely obvious stuff.
I'm still somewhat bemused at the layer upon layer of technical administration, that did not realise such a simple thing.
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There is much comment on this thread of worthy debate. In a previous life, I was President of a highly publicised Tornado GR1 BoI, a member of two others of different aircraft, and staffed many more as a Group staff officer. I was also the SFSO at RAF Muharraq. In all of that, I was always master of my own words, written or spoken. And at times my superiors weren't best pleased with my views - one in particular. But I always stood my ground, and came through unscathed, to a degree.
I was also required to carry out AOC's administrative inspections, on an annual basis, of several squadrons: ensuring, on the AOC's behalf, that each unit was adhering to the laid down requirements of IF/Sim /SCT/Ann Cx etc etc. I emphasise that this was a demand of my AOC, as a means of discipline. It ensured that all of his flying units conformed to laid down procedures, which helped to ensure safe operation. Safe and Operation being key words. It was a necessary pain, for all of us. But it was also a 'measure' of a unit's psyche.
That was many years ago. So some may say that I'm no longer in tune. I would disagree.
My view is that the SI is correct in its findings. The cause of the accident is straightforward (the pin et al), the cause of death is straightforward (the shackle et al). There was also a finding of some routine malpractice within the RAFAT organisation that fell below professional requirements; which, whilst not contributing directly to either cause, engendered a systemic lapse in behaviour.
I'm sure all things will now be in order.
As a Hawk pilot of old, I was aware of the 'pin placement problem' many years ago. As many were. I leave it to others elsewhere to carry on with that issue.
Meanwhile, good luck to all in the Team this year.
I was also required to carry out AOC's administrative inspections, on an annual basis, of several squadrons: ensuring, on the AOC's behalf, that each unit was adhering to the laid down requirements of IF/Sim /SCT/Ann Cx etc etc. I emphasise that this was a demand of my AOC, as a means of discipline. It ensured that all of his flying units conformed to laid down procedures, which helped to ensure safe operation. Safe and Operation being key words. It was a necessary pain, for all of us. But it was also a 'measure' of a unit's psyche.
That was many years ago. So some may say that I'm no longer in tune. I would disagree.
My view is that the SI is correct in its findings. The cause of the accident is straightforward (the pin et al), the cause of death is straightforward (the shackle et al). There was also a finding of some routine malpractice within the RAFAT organisation that fell below professional requirements; which, whilst not contributing directly to either cause, engendered a systemic lapse in behaviour.
I'm sure all things will now be in order.
As a Hawk pilot of old, I was aware of the 'pin placement problem' many years ago. As many were. I leave it to others elsewhere to carry on with that issue.
Meanwhile, good luck to all in the Team this year.
Last edited by cuefaye; 12th Feb 2014 at 09:04.
Hear, hear, cuefeye.
Tuc,
I agree. My point was that the SI has fulfilled its remit (very well, in my view). It is the next step that you (correctly in my view) are questioning. But they are two separate issues. Had the Panel raised the issues you mention they would be firmly told to wind their necks in. That was my point.
Tuc,
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.
CM
I have said the SI went further than most and I, too, think they did a good job. A few howlers and a bit simplistic in places but no serving officer would be expected to know the proper answers to many of the issues.
But,
That is surely the problem. They should feel confident of support at the highest level if they raise, AGAIN, systemic failings. Anyone who tells an SI to wind their necks in for revealing such gross failings on a safety critical equipment should be dismissed immediately. If an SI feels it must criticise those it reports to (e.g. MAA) then it should have an alternative route to submit its report. Reading this report is like reading the MoK one in places. You think, good, excellent, you're getting there.........then, nothing. An abrupt change of direction and the previous section is obviously incomplete, or has been edited by someone. The giveaway is the odd sentence here and there that should also have been deleted for continuity and consistency.
Just my opinion.
Now an irrefutable fact. Failure to notify and take action protects the same old VSOs and their successors. It is why those with oversight should be independent.
Flight Idle
Precisely. I said the same thing earlier in the thread. Ist year apprentice stuff. But we don't do apprentices anymore.
Simple answer. The SI correctly notes the warning was dated 1991, but it fails to ask the question as of that date. It only asks the current set up, which didn't exist pre-1999. It was the same on Chinook and others. They asked the IPT, formed in 1999, "In 1993 did you ......" and they said, correctly, No. But they didn't ask anyone who would be expected to know the truth.
If you ask any ATP staff from 1991 why the warning would not get into the APs (I have, it is one phone call, so why not the SI - it would have significantly changed their report and recommendations?) you get a perfectly reasonable explanation. That is, funding was being chopped, posts cut and ATP due to be transferred to Glasgow, but none of the staff with it as they were seeking retirement packages. By 1992 all ATP amendments were stopped by the Chief Engineer's organisation, as part of his rundown of airworthiness. 28% cuts in direct airworthiness funding simply cannot be tolerated year on year without major problems. That is what made this and other accidents inevitable. And it is what the MAA are continuing to hide.
I say again. The chances of Martin Baker not sending this servicing bulletin to MoD are slim to zero. The SI does not claim MoD never got it, only that it cannot be found. (But at the inquest this had become MoD didn't get it, and one must ask when this leap occurred and why). But who did they ask? No-one who would be expected to have it, given the above regime and policies of the day. All MB said in court was "I wasn't there at the time". So why didn't the Coroner demand a witness appear who was there? It is up to the MAA to fill in these gaps. They won't. Therefore it must be someone independent of MoD. I suggest a Law Lord.
I have said the SI went further than most and I, too, think they did a good job. A few howlers and a bit simplistic in places but no serving officer would be expected to know the proper answers to many of the issues.
But,
Had the Panel raised the issues you mention they would be firmly told to wind their necks in.
That is surely the problem. They should feel confident of support at the highest level if they raise, AGAIN, systemic failings. Anyone who tells an SI to wind their necks in for revealing such gross failings on a safety critical equipment should be dismissed immediately. If an SI feels it must criticise those it reports to (e.g. MAA) then it should have an alternative route to submit its report. Reading this report is like reading the MoK one in places. You think, good, excellent, you're getting there.........then, nothing. An abrupt change of direction and the previous section is obviously incomplete, or has been edited by someone. The giveaway is the odd sentence here and there that should also have been deleted for continuity and consistency.
Just my opinion.
Now an irrefutable fact. Failure to notify and take action protects the same old VSOs and their successors. It is why those with oversight should be independent.
Flight Idle
A simple feeler gauge check for gap between the mechanism, bolt, nut etc, is all that is required on the scissor shackle.
It seems to me, first year student stuff, quite obvious to anyone really & no, it's not hindsight, just completely obvious stuff.
It seems to me, first year student stuff, quite obvious to anyone really & no, it's not hindsight, just completely obvious stuff.
Precisely. I said the same thing earlier in the thread. Ist year apprentice stuff. But we don't do apprentices anymore.
I'm still somewhat bemused at the layer upon layer of technical administration, that did not realise such a simple thing.
Simple answer. The SI correctly notes the warning was dated 1991, but it fails to ask the question as of that date. It only asks the current set up, which didn't exist pre-1999. It was the same on Chinook and others. They asked the IPT, formed in 1999, "In 1993 did you ......" and they said, correctly, No. But they didn't ask anyone who would be expected to know the truth.
If you ask any ATP staff from 1991 why the warning would not get into the APs (I have, it is one phone call, so why not the SI - it would have significantly changed their report and recommendations?) you get a perfectly reasonable explanation. That is, funding was being chopped, posts cut and ATP due to be transferred to Glasgow, but none of the staff with it as they were seeking retirement packages. By 1992 all ATP amendments were stopped by the Chief Engineer's organisation, as part of his rundown of airworthiness. 28% cuts in direct airworthiness funding simply cannot be tolerated year on year without major problems. That is what made this and other accidents inevitable. And it is what the MAA are continuing to hide.
I say again. The chances of Martin Baker not sending this servicing bulletin to MoD are slim to zero. The SI does not claim MoD never got it, only that it cannot be found. (But at the inquest this had become MoD didn't get it, and one must ask when this leap occurred and why). But who did they ask? No-one who would be expected to have it, given the above regime and policies of the day. All MB said in court was "I wasn't there at the time". So why didn't the Coroner demand a witness appear who was there? It is up to the MAA to fill in these gaps. They won't. Therefore it must be someone independent of MoD. I suggest a Law Lord.
A simple feeler gauge check for gap between the mechanism, bolt, nut etc, is all that is required on the scissor shackle.
You are right though in saying that some sort of gap measuring device would do the trick.
CM:-
Before going into full repel boarders mode could I politely suggest just sitting on our hands and thinking this one out for a while? Every previous airworthiness related fatal accident thread on this forum has entailed a circling of the wagons at the very suggestion that VSOs were not only involved in that deficit of airworthiness but had been responsible for causing it, while others ensured that had been covered up and go on trying to do so.
Accepting that is the nettle that has to be grasped is necessary if you love the Royal Air Force, for defending the indefensible can have only one outcome, that is the continual spread of unairworthiness throughout the military airfleets, further airworthiness related accidents (often fatal), and further accident investigations that fail to detect it.
A system of investigation that has the premise that investigations must conform to what they may investigate and what they may not (and if they do that to be told "to wind their necks in"), is not fit for purpose. It is a measure of the rot when we are told that the DG MAA has commended this Report. He might well do so, for it diverts attention from the real cause of this accident, Gross Unairworthiness, for which he is responsible.
Hear, hear, cuefeye.
Accepting that is the nettle that has to be grasped is necessary if you love the Royal Air Force, for defending the indefensible can have only one outcome, that is the continual spread of unairworthiness throughout the military airfleets, further airworthiness related accidents (often fatal), and further accident investigations that fail to detect it.
A system of investigation that has the premise that investigations must conform to what they may investigate and what they may not (and if they do that to be told "to wind their necks in"), is not fit for purpose. It is a measure of the rot when we are told that the DG MAA has commended this Report. He might well do so, for it diverts attention from the real cause of this accident, Gross Unairworthiness, for which he is responsible.
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Is a nut and bolt needed here? Surely a bolt without threads secured with a split pin or similar would suffice. From what I read there is little force exerted on the shackle which would make it open. Alternatively, a bolt with a much shorter threaded section and locknut.
Point taken, Chug, but you've misinterpreted what I've said as well. I am neither defending nor attacking the system that you say is broken; I am am simply saying that the Boards/Panels (esp the one in this case) have gone as far as they can. The rest, as you and tuc illustrate frequently and very thoroughly, needs to be sorted elsewhere, possibly using SI reports etc as part of their evidence.
B Noise
Your post ably demonstrates many people in MoD knew of this problem and how to avoid it. MoD's entire case centres on alleged ignorance of all concerned, blaming Martin Baker.
There are a number of inspection methods that would have avoided it. But the SI report opines the lock nut was cranked down so tight it cut new thread on the bolt. This would be easy to prove, but they don't try - they just leave it as an opinion. But you can FEEL yourself cutting new thread. It is a warning something is amiss. I suspect it was the first thing noticed by the engineer who looked at it during the investigation, yet omitted.
I asked before; I wonder if the lock-nut was new? A relatively recent maintenance regime meant it was removed more frequently (every 50 hours) so the obvious question, again not asked by the SI, was if extra provision had been made to ensure more spare nuts. A minor detail to some, but the bane of a maintainer's existence.
Was there a self-certification regime?
Your post ably demonstrates many people in MoD knew of this problem and how to avoid it. MoD's entire case centres on alleged ignorance of all concerned, blaming Martin Baker.
There are a number of inspection methods that would have avoided it. But the SI report opines the lock nut was cranked down so tight it cut new thread on the bolt. This would be easy to prove, but they don't try - they just leave it as an opinion. But you can FEEL yourself cutting new thread. It is a warning something is amiss. I suspect it was the first thing noticed by the engineer who looked at it during the investigation, yet omitted.
I asked before; I wonder if the lock-nut was new? A relatively recent maintenance regime meant it was removed more frequently (every 50 hours) so the obvious question, again not asked by the SI, was if extra provision had been made to ensure more spare nuts. A minor detail to some, but the bane of a maintainer's existence.
Was there a self-certification regime?
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The rest, as you and tuc illustrate frequently and very thoroughly, needs to be sorted elsewhere, possibly using SI reports etc as part of their evidence.
Agreed Cm - which I should have made more clear in my penultimate sentence.
Agreed Cm - which I should have made more clear in my penultimate sentence.
CM, I'm not sure if we are in violent agreement or disagreement. When you say:-
is that because they are simply doing what they are told rather than determining the accident cause no matter what, or that given their limited access to evidence (because they are not made aware of it, or it is simply denied them) they can do no more?
Either way it is a waste of time and resource in my book, and fails in its principal purpose, ie to prevent a recurrence.
I am simply saying that the Boards/Panels (esp the one in this case) have gone as far as they can.
Either way it is a waste of time and resource in my book, and fails in its principal purpose, ie to prevent a recurrence.
Simple answer. The SI correctly notes the warning was dated 1991, but it fails to ask the question as of that date. It only asks the current set up, which didn't exist pre-1999. It was the same on Chinook and others. They asked the IPT, formed in 1999, "In 1993 did you ......" and they said, correctly, No. But they didn't ask anyone who would be expected to know the truth.
Surely a bolt without threads secured with a split pin or similar would suffice.
For some extraordinary reason the AAIB thought it was. BoI President instructed to say "not determined". (Evidence to ZD576 Fatal Accident Inquiry).
dctyke
The relatively recent Routine Technical Instruction requiring crack detection necessitated removal of said nut and bolt. From memory, the last application was about 3 weeks before the accident (Oct 2011). The RTI (and UTI before it) periodicity was changed a number of times and the SI report notes concern was expressed over the increased maintenance burden on RAFAT, compounded by loss of many engineers.
Sorry, I meant to add; did you spot the error in terminology in the report? They called the RTI a Special Technical Instruction (which the MAA call a Service Technical Instruction...). It is neither.
All this became very confusing in the mid-00s as they changed a lot of terms and definitions unnecessarily, which would force anyone taught under the old and perfectly good system to think long and hard about hitherto no-brainers. This was compounded by the long standing POLICY of ignoring the mandated POLICY for independent oversight of SI(T) approvals. I have a fundamental issue with PTs being allowed to both propose and approve these.
The relatively recent Routine Technical Instruction requiring crack detection necessitated removal of said nut and bolt. From memory, the last application was about 3 weeks before the accident (Oct 2011). The RTI (and UTI before it) periodicity was changed a number of times and the SI report notes concern was expressed over the increased maintenance burden on RAFAT, compounded by loss of many engineers.
Sorry, I meant to add; did you spot the error in terminology in the report? They called the RTI a Special Technical Instruction (which the MAA call a Service Technical Instruction...). It is neither.
All this became very confusing in the mid-00s as they changed a lot of terms and definitions unnecessarily, which would force anyone taught under the old and perfectly good system to think long and hard about hitherto no-brainers. This was compounded by the long standing POLICY of ignoring the mandated POLICY for independent oversight of SI(T) approvals. I have a fundamental issue with PTs being allowed to both propose and approve these.
Your post ably demonstrates many people in MoD knew of this problem and how to avoid it.
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Cuefaye, you state;
What action did you take? Did you bring it to the attention of higher authority?
DV
As a Hawk pilot of old, I was aware of the 'pin placement problem' many years ago. As many were
DV
B Noise
Sorry, I misconstrued your post.
My point is that if the SI isn’t permitted to go as far as a reasonable person would expect then, lacking any airworthiness expertise of their own, the MAA should at least pass the draft to someone who knows about such things, if only to ensure a little consistency and avoid MoD looking very very stupid.
They didn’t, and the reason is clear when one considers what was allowed to be said at the inquest. And such a policy is entirely in keeping with previous policies of those it is designed to protect. For example, the Chief Engineer expressly forbade the ARTs from speaking to MoD’s airworthiness experts. Their reports displayed the same characteristics. On the face of it pretty comprehensive, but actually so lacking in depth as to demand a proper technical investigation and reconvening of both SI and Inquest.
Sorry, I misconstrued your post.
My point is that if the SI isn’t permitted to go as far as a reasonable person would expect then, lacking any airworthiness expertise of their own, the MAA should at least pass the draft to someone who knows about such things, if only to ensure a little consistency and avoid MoD looking very very stupid.
They didn’t, and the reason is clear when one considers what was allowed to be said at the inquest. And such a policy is entirely in keeping with previous policies of those it is designed to protect. For example, the Chief Engineer expressly forbade the ARTs from speaking to MoD’s airworthiness experts. Their reports displayed the same characteristics. On the face of it pretty comprehensive, but actually so lacking in depth as to demand a proper technical investigation and reconvening of both SI and Inquest.