Flt. Lt. Sean Cunningham inquest
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I accept that times have changed since I left, and through various channels, including this forum, I am also aware of the many reductions and restrictions the RAF have been subject to. Equipment shortages, manpower shortages, over-tasking, JPA, lack of identity through the wearing of Army style combat fatigues, increases in specialised tasks being farmed out to civil contractors, the gifting of Harriers to the US, no MPA, gross wastage of money on unnecessary projects, base closures, complete detachment of their airships from the mainstream, etc, etc. This has led to unbelievably low morale in all areas.
What I hadn't realised until I read the SI was just how low the general standards of operating and training had become. I am not going to knock RAFAT. I still think they are our best flag waver and advert for the RAF. They also form a window into the RAF in general. If things are bad at the RAF's premier and high-visibility asset, what chance for the rest of the guys and gals in blue? The pressures they were under at the time were not acceptable, a situation again reflected in the wider RAF. The shocking revelations that have been recorded in this SI suggest this only too clearly.
Overstress and Courtney,
When I joined the Hawk fleet in '79, the first thing every and all engineering staff were subjected to was Ejection Seat initial briefing. The intro was in the seat bay, and was always given by a SNCO Armourer employed in the seat bay. This was subject to a six-monthly repetitive refamil, and was recorded on our personal files. Some things in life you tend to remember with great clarity. If it is something that can kill you quick, you generally make a point of paying attention. Seat lectures were one of those occasions. 35 years later, most of that first brief about the Mk 10 seat is still crystal clear in my head, starting with "This chair is going to try and kill you in lots of different ways, and I am going to tell you how to stay alive".
The gotcha pin-in-SFH-out (position 2 in the SI) was not only known about, but highlighted and emphasised to us at each and every briefing. So, it was clearly well known then.
I was stunned to read in the SI the Reds had an engineering member who had not yet received a seat lecture. Was he actually involved in the maintenance of the aircraft at the time in a hands-on manner?
Camlobe
What I hadn't realised until I read the SI was just how low the general standards of operating and training had become. I am not going to knock RAFAT. I still think they are our best flag waver and advert for the RAF. They also form a window into the RAF in general. If things are bad at the RAF's premier and high-visibility asset, what chance for the rest of the guys and gals in blue? The pressures they were under at the time were not acceptable, a situation again reflected in the wider RAF. The shocking revelations that have been recorded in this SI suggest this only too clearly.
Overstress and Courtney,
When I joined the Hawk fleet in '79, the first thing every and all engineering staff were subjected to was Ejection Seat initial briefing. The intro was in the seat bay, and was always given by a SNCO Armourer employed in the seat bay. This was subject to a six-monthly repetitive refamil, and was recorded on our personal files. Some things in life you tend to remember with great clarity. If it is something that can kill you quick, you generally make a point of paying attention. Seat lectures were one of those occasions. 35 years later, most of that first brief about the Mk 10 seat is still crystal clear in my head, starting with "This chair is going to try and kill you in lots of different ways, and I am going to tell you how to stay alive".
The gotcha pin-in-SFH-out (position 2 in the SI) was not only known about, but highlighted and emphasised to us at each and every briefing. So, it was clearly well known then.
I was stunned to read in the SI the Reds had an engineering member who had not yet received a seat lecture. Was he actually involved in the maintenance of the aircraft at the time in a hands-on manner?
Camlobe
It could NOT be overtightened when fitted in the seat bay because it (the drogue shackle) was pre-assembled (bolt already fitted) before sliding into an open scissor shackle and the BTRU cocked. If it was too tight it would simply of not have gone into the scissor shackle. It was the advent of extending seat servicing times in recent years which meant they had to frig a way of undoing the drogue shackle bolt to enable the beam crack testing to be carried out. Simply the shackle system was never really designed to have the bolt removed/fitted in-situ.
I admit its been a while and memory is fuzzy.
Disturbing systems that are meant to be left alone usually has some undesirable hidden consequence.
downsizer
Can't self certify seat work.
The recurring systemic failure that this case highlights, yet again, is that it has become the norm not to verify functional safety. This was waived many years ago, and was directly responsible for e.g Tornado/Patriot (2003). One of the last posts on the Spry thread noted the wrong definition is now used by MoD! That's what happens when you stop teaching and doing it. Very similar to the points made by Camlobe about seat training.
Now that we are pondering over dctyke's 2nd post re in situ removal of the shackle bolt, I thought it might help if we remind ourselves of what he said first time round (sorry dct, pennies are at last beginning to drop) :-
So for most of its life this seat was removed from the aircraft to be serviced in the station seat bay once a year. Then the savings at the expense of we know what kick in, and it stays in the aircraft for two years, then three years, then it is taken to some far away centralised servicing depot.
In the meantime it becomes necessary to perform testing for beam cracks at more frequent intervals, ie while the seat is in the aircraft. Can't be done because the shackle is in the way and the scissor shackle can't be opened to release it. So undo the bolt and remove it that way, carry out the test and then replace the shackle and do up the bolt. Simples! Only trouble is MB didn't design it for that procedure. So what I would like to know is what is the process required to ensure that the new procedure is safe, before it is cleared to be carried out on the line?
In 1991 that seat would have been serviced every 12 months. If the crack testing was being done then it would have been in the seat bay. The shackle bolt would never have been fitted/removed/fitted in-situ as it is done now. Even in 1999 this was the case. Sometime after that a decision was made to extend seat servicing to two, then three years. Someone devised the new proceedure of removing the shackle bolt in-situ to accomodate crack testing as it's phase was shorter than the extended seat bay servicing times.
In the meantime it becomes necessary to perform testing for beam cracks at more frequent intervals, ie while the seat is in the aircraft. Can't be done because the shackle is in the way and the scissor shackle can't be opened to release it. So undo the bolt and remove it that way, carry out the test and then replace the shackle and do up the bolt. Simples! Only trouble is MB didn't design it for that procedure. So what I would like to know is what is the process required to ensure that the new procedure is safe, before it is cleared to be carried out on the line?
Are you sure? If so how were headbox changes done 1st line?
Well, not a complete farce.
But the withholding of the report until after the inquest prevented reasoned, informed discussion which we're now seeing here. As stated before.
This information should now be submitted, perhaps through ones MP, for the Secretary of State to consider ordering the SI to reconvene, that they may hear this evidence for the first time.
And then see what impact it has on their conclusions and recommendations.
But the withholding of the report until after the inquest prevented reasoned, informed discussion which we're now seeing here. As stated before.
This information should now be submitted, perhaps through ones MP, for the Secretary of State to consider ordering the SI to reconvene, that they may hear this evidence for the first time.
And then see what impact it has on their conclusions and recommendations.
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Since the publication of the SI report a week ago, some 210 posts have been added to this thread. The vast majority have not contained "rumour" or speculation, but facts. Facts that should have been made avaliable to SI or the coroner. In fact, I believe that at least four posters should have given evidence at the inquest. But of course MOD did not want that, nor do they want all the facts to be presented at the Tornado FAI, if it takes place; hence the withholding of the SI report, and ultimately vital evidence.
DV
DV
DV and others - given this seat type is being used daily - is it not better to try and get to a cause and try and mitigate for that cause as soon as possible?
In an academic/ideal world, all these individuals could have given evidence/been interviewed, but how long would that have taken?
As someone who had to fly on an aircraft while awaiting the result of a SI for that type, I know I was VERY keen for solutions to be implemented as soon as possible, even if it did make the investigation less thorough than otherwise may have been.
I agree that many of the observations on here should be captured to help sort any other preventative measures that can be implemented, but I wouldn't have liked to have seen that hold up remedial actions in the meantime.
Maybe that should be explored at the MAA? Perhaps a 'cold case' specialist who re-examines closed events and looks for further evidence subsequently presented in places such as this?
Unfortunately, I know that the time that can be allocated to these events (as important as they are) at station level is limited due to the need to continue with the myriad of other tasks.
In an academic/ideal world, all these individuals could have given evidence/been interviewed, but how long would that have taken?
As someone who had to fly on an aircraft while awaiting the result of a SI for that type, I know I was VERY keen for solutions to be implemented as soon as possible, even if it did make the investigation less thorough than otherwise may have been.
I agree that many of the observations on here should be captured to help sort any other preventative measures that can be implemented, but I wouldn't have liked to have seen that hold up remedial actions in the meantime.
Maybe that should be explored at the MAA? Perhaps a 'cold case' specialist who re-examines closed events and looks for further evidence subsequently presented in places such as this?
Unfortunately, I know that the time that can be allocated to these events (as important as they are) at station level is limited due to the need to continue with the myriad of other tasks.
Maybe that should be explored at the MAA? Perhaps a 'cold case' specialist who re-examines closed events and looks for further evidence subsequently presented in places such as this?
Excellent suggestion. MAA? Not independent. I'd say the best candidates already post here on pprune. The detailed evidence dug up and given to Phillip on ZD576 was astonishing. Nobody in MoD got close.
Excellent suggestion SP, with one slight drawback as Dervish points out. Your eagle eyed Holmes spots the recurring theme in numerous BoI/SI reports of airworthiness deficiency, traces the timeline back to the late 80's/ early 90's and discovers a 28% year on year slashing of the Air Safety budget by the then RAF Chief Engineer. He hands in his finding to the DG MAA who bins it saying, "This is not new evidence". End of!
The Royal Air Force High Command lacks the moral courage to lance this boil. That is why the MAA and the MAAIB must be made independent of the MOD and of each other.
dctyke, thank you for your confirmation that I got your information right, and I am now intrigued by the issue raised between downsizer and yourself. What about the parachute? Presumably it didn't sit in the aircraft for three years, like the seat (though I dread being told that is exactly the case). So is the headbox change at the same time as an RTI crack check? If so is it therefore included in the RTI? If not is it the subject of a different Special Instruction (Technical)? Anyone?
The Royal Air Force High Command lacks the moral courage to lance this boil. That is why the MAA and the MAAIB must be made independent of the MOD and of each other.
dctyke, thank you for your confirmation that I got your information right, and I am now intrigued by the issue raised between downsizer and yourself. What about the parachute? Presumably it didn't sit in the aircraft for three years, like the seat (though I dread being told that is exactly the case). So is the headbox change at the same time as an RTI crack check? If so is it therefore included in the RTI? If not is it the subject of a different Special Instruction (Technical)? Anyone?
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The gotcha pin-in-SFH-out (position 2 in the SI) was not only known about, but highlighted and emphasised to us at each and every briefing.
Pilots will recall the dummy seat in the ground school classroom where one could practise strapping in, making the seat live/safe and pulling the handle, (and re-setting it afterwards) so all Hawk pilots will have had a go at that.
The gotcha pin-in-SFH-out (position 2 in the SI) was not only known about, but highlighted and emphasised to us at each and every briefing.
If I recall from the SI, they did tests with pilots who were not informed of what the test was about and they did not realise when they inserted the pin into a position 2 SPH.
This surely suggests that all current hawk/Mk10 users are (or were upto SI) unaware of this risk/issue - it has been institutionally forgotten.
I'd like to know if any recall if it was originally written down - you could expect something in the tech pubs - and if so if somehow this has been deleted through updates, or perhaps through changes in training courses?
Last edited by JFZ90; 13th Feb 2014 at 20:12. Reason: edited due to camlobe comment below to clarify pre SI
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Overstress,
You are very welcome.
JFZ90,
Prior to the publication of the SI, I would have agreed with your comment regarding being forgotten. I suspect that every current RAF user is completely familiar with this scenario...just as they were 30+ years ago.
Camlobe
You are very welcome.
JFZ90,
Prior to the publication of the SI, I would have agreed with your comment regarding being forgotten. I suspect that every current RAF user is completely familiar with this scenario...just as they were 30+ years ago.
Camlobe
camlobe - yes of course - I meant up to the point of the SI - I'm sure there is no risk at all now for any Mk10 users - everyone is more than aware of the risk as I suspect every Mk10 user has read the SI cover to cover and is no doubt extra careful with e.g. their straps.
Have to admit I did not know they did, and if so they would indeed need to release the shackle some way. In my time it was only done in the bay. However, like the crack testing. Was the advent of changing head boxes 1st line introduced to accomodate the extended seat serving times?
downsizer, might I ask what period that might be? Do you know what procedure was used?
As I understand it, it would have to be much the same as the crack check, ie undo Shackle bolt and withdraw from scissor jaws, change box, thread new bolt through shackle and scissor jaws, tighten up new nut. Am I right?
As I understand it, it would have to be much the same as the crack check, ie undo Shackle bolt and withdraw from scissor jaws, change box, thread new bolt through shackle and scissor jaws, tighten up new nut. Am I right?