Flt. Lt. Sean Cunningham inquest
Back to the thread, having read the report there is mention of a standard for the threads protuding through the nut but no mention of standard torque figures.If no torque specified then use standard practises. As per report this had been overtightened so that new threads were cut in the bolt. No mention of how much effort would have been required to achieve this which i think would be relevant. Not just a problem for the RAF , but in my experience basic handskills has suffered in the last few years with the reduction in proper hand skills training in the whole industry. Basic engineering also teaches that a shackle bolt doesnt need to be tight, just secure as it operates in shear. Just such a shame that a simple error like this cost a life, most errors like this never cause a problem
Join Date: Dec 2007
Location: Pasadena
Posts: 633
Likes: 0
Received 0 Likes
on
0 Posts
My understanding is that the bolt is supposed to be movable by hand. As such, it might be a more appropriate location for a pin. I'm not sure threads are the ideal fastener at this point, especially if people lose track of them supposed to being loose and perhaps fall victim to a natural tendency to want to tighten everything up thirty years after the device first entered service.
Inscribing a torque setting and bolt specification next to the hole would have been a nice design touch back in the day, although it's not easy to specify a degree of looseness. Perhaps the manufacturer believed that only seasoned experts who knew everything backwards and in the dark would ever handle the bolts?
Trying to find out when the new threads were cut does seem to be a potential route to weeding out safety flaws that may crop up elsewhere. It's been asked before - it would be interesting to know (not necessarily on this forum) whether there were other seats in service with the same issue.
Hand skills are an issue, aren't they? In the days of additive manufacturing, you might be able to print a bolt on your desk, but do you know how to tighten it and whether to coat it with anything before you do?
Fortunately, there's not so may errors that focus on such a safety critical single-point failure of a part that's not tested, but still has to be right. But, it's still very sad, and it seems to be down to a loss of manual skill and craftsmanship in the pursuit of relatively modest savings.
Inscribing a torque setting and bolt specification next to the hole would have been a nice design touch back in the day, although it's not easy to specify a degree of looseness. Perhaps the manufacturer believed that only seasoned experts who knew everything backwards and in the dark would ever handle the bolts?
Trying to find out when the new threads were cut does seem to be a potential route to weeding out safety flaws that may crop up elsewhere. It's been asked before - it would be interesting to know (not necessarily on this forum) whether there were other seats in service with the same issue.
Hand skills are an issue, aren't they? In the days of additive manufacturing, you might be able to print a bolt on your desk, but do you know how to tighten it and whether to coat it with anything before you do?
Fortunately, there's not so may errors that focus on such a safety critical single-point failure of a part that's not tested, but still has to be right. But, it's still very sad, and it seems to be down to a loss of manual skill and craftsmanship in the pursuit of relatively modest savings.
awblain
Excellent post. Well said.
There are a couple of pointed questions to be asked.
1. How many staff in DE&S with airworthiness delegation have hands-on experience of servicing and/or maintaining aircraft AND their components? In 1990, both were mandatory. In 1991, both were frowned upon by the RAF Chief Engineer’s organisation, whose 2 Star (DGSM) decreed that henceforth all admin staff would be senior to all engineers. That speaks volumes.
2. How many staff in the MAA have reported systemic airworthiness failures? (Fact – MoD state none.) If you haven’t, and knew about them, you’ve committed an offence, and we don’t want you working in the MAA. If you haven’t, and didn’t realise there were failures, what the hell are you doing working in the MAA?
Conclusion. MoD is in the **** and sinking fast, due entirely to VSOs running down airworthiness to hide their own wasteful policies. Do your job, or resign. You’re killing too many good men.
Excellent post. Well said.
There are a couple of pointed questions to be asked.
1. How many staff in DE&S with airworthiness delegation have hands-on experience of servicing and/or maintaining aircraft AND their components? In 1990, both were mandatory. In 1991, both were frowned upon by the RAF Chief Engineer’s organisation, whose 2 Star (DGSM) decreed that henceforth all admin staff would be senior to all engineers. That speaks volumes.
2. How many staff in the MAA have reported systemic airworthiness failures? (Fact – MoD state none.) If you haven’t, and knew about them, you’ve committed an offence, and we don’t want you working in the MAA. If you haven’t, and didn’t realise there were failures, what the hell are you doing working in the MAA?
Conclusion. MoD is in the **** and sinking fast, due entirely to VSOs running down airworthiness to hide their own wasteful policies. Do your job, or resign. You’re killing too many good men.
I cannot recall anyone in the Service openly criticising the conduct of a Service Inquiry before to the point of complaining of unfair treatment. Sqn Ldr Turner's comments to the press may have been in an unguarded moment but they do suggest that he, as OC RAFAT, is not content with the Inquiry or its findings. I'm not sure that open dissent is ever helpful, especially given the tragic and unnecessary loss of life.
Originally Posted by Grimsby Telegraph - 21 Feb 14
Elements of the recent Ministry of Defence Service Inquiry report into the tragic death of Flt Lt Sean Cunningham were critical of the conduct of the Red Arrows and Sqn Ldr Turner insists he and the rest of the team were left “hurt” by some of its contents.
“It was a horribly tragic accident that could have happened to any fast jet unit,” he said. “I feel that we’ve been singled out for some unfair treatment by elements of the Service Inquiry and I am very keen to prove to people that we are as professional, if not the most professional, unit in the RAF. The treatment hurt me very much. It hurt all of us. We all believe in this job, the engineers and the pilots, we are all keen on showcasing the excellence of the Red Arrows.”
“It was a horribly tragic accident that could have happened to any fast jet unit,” he said. “I feel that we’ve been singled out for some unfair treatment by elements of the Service Inquiry and I am very keen to prove to people that we are as professional, if not the most professional, unit in the RAF. The treatment hurt me very much. It hurt all of us. We all believe in this job, the engineers and the pilots, we are all keen on showcasing the excellence of the Red Arrows.”
Join Date: Nov 2009
Location: Down West
Posts: 156
Likes: 0
Received 0 Likes
on
0 Posts
bvcu, awblain,
I have occasionally looked at this thread and I'm sure it's been mentioned before, but torque loadings are covered even when they're not specified. The aircraft APs have a section (topic 6 I think for Seaking) that specifically gives max torque settings for different diameter bolts/studs etc. It covers everything you need to know to safely tighten a fastener where the procedure doesn't give a setting, hence no need to etch on a bolt or such like.
An example from memory would be the trunnions that hold the primary servo jacks onto the gearbox on a Seaking, they are ( i'm sure you would agree) pretty critical. When I worked on the beastie I'm sure they weren't torque loaded, but you obtained the figure for the maximum torque from the AP, factored in run down torque and tightened the nut. The nut was in safety the torque was in safety and everyone was happy.
The fact that MAP (formally JAP) has it's own section on assisted escape devices independent checks, should have caught any overtightening I would have thought, but I do admit I haven't worked on bang seats since Seafield park training.
Cheers now
I have occasionally looked at this thread and I'm sure it's been mentioned before, but torque loadings are covered even when they're not specified. The aircraft APs have a section (topic 6 I think for Seaking) that specifically gives max torque settings for different diameter bolts/studs etc. It covers everything you need to know to safely tighten a fastener where the procedure doesn't give a setting, hence no need to etch on a bolt or such like.
An example from memory would be the trunnions that hold the primary servo jacks onto the gearbox on a Seaking, they are ( i'm sure you would agree) pretty critical. When I worked on the beastie I'm sure they weren't torque loaded, but you obtained the figure for the maximum torque from the AP, factored in run down torque and tightened the nut. The nut was in safety the torque was in safety and everyone was happy.
The fact that MAP (formally JAP) has it's own section on assisted escape devices independent checks, should have caught any overtightening I would have thought, but I do admit I haven't worked on bang seats since Seafield park training.
Cheers now
Join Date: Apr 2004
Location: Erehwon
Posts: 1,146
Likes: 0
Received 0 Likes
on
0 Posts
Hmm, I too have never seen published criticism of an SI by a serving member of any appointment. Sign of the times?
As has been said many times, there are no winners and whilst the main points have been covered ad nauseum, these inquiries are tasked to look at everything and RAFAT's standard practices obviouly did not find favour with the Board.
Due to their somewhat unique role, this may or may not be acceptable to Duty Holders further up the food chain. The Board have done their job subjected to intense media scrutiny (including this very forum), so that is additionally difficult.
NB I spent three years as an SFSO on a (nominally) fast jet station in a previous life, so find the Board's conclusions unsurprising.
THERE ARE NO WINNERS
As has been said many times, there are no winners and whilst the main points have been covered ad nauseum, these inquiries are tasked to look at everything and RAFAT's standard practices obviouly did not find favour with the Board.
Due to their somewhat unique role, this may or may not be acceptable to Duty Holders further up the food chain. The Board have done their job subjected to intense media scrutiny (including this very forum), so that is additionally difficult.
NB I spent three years as an SFSO on a (nominally) fast jet station in a previous life, so find the Board's conclusions unsurprising.
THERE ARE NO WINNERS
JTO
I, too, am with Sqn Ldr Turner on this one. The SI report details some poor lapses at RAFAT but what it actually describes is very serious and criminal SYSTEMIC and ORGANISATIONAL failures. Same as all the other cases we discuss here.
The way it is written is appalling. But, like many such reports, the feeling is there was much more and it has been heavily edited. You know, because MoD doesn't ensure it is consistent and makes sense, post-edit. (See ZD576 - we've been here before). Like many reports, it presents uninformed personal opinions as fact, while ignoring demonstrable fact. (See XV650/704 - we've been here before....).
The purpose of the SI is to identify causes and help prevent recurrence, but there is absolutely no depth to the engineering investigation whatsoever. It may look like there is; lots of diagrams of nuts, bolts and shackles, but this is basic, first year apprentice stuff. Pilots may topple or even be impressed, but engineers cringe. But if you list all the components of the process involved in ensuring that seat is safe, and used safely, then it barely touches most of them. I've said before, part of the reason is because MoD simply don't "do" this discipline anymore. 20 years after the Chinook safety case warning, which developed after the RAF Chief Engineer stopped such work, here we are with a safety critical system with no safety case. That is not the fault of RAFAT in any way, yet it is THE major failing because it is so fundamental everything else is affected. In case the MAA claim they haven't had enough time to correct this, the more recent Nimrod case was not a revelation, it was wholly predicted and advised to senior staffs and Ministers repeatedly over that 20 year period. The MAA INHERITED 20 years of very detailed and precise warnings, which time after time have been proven absolutely correct. But they say their clock started when they were formed, as if Haddon-Cave was a surprise. All he did was collate 20 years worth of recommendations, which were sat on the desks of various 3 and 4 Stars.
Regarding the laughably incompetent and criminal lack of a seat safety case. Having discovered that (well done the SI; it is the obvious question but so few ask it) then a significant portion of the report should have been aimed at WHY. Instead, it just moves on as if it is insignificant. I wonder if this part was edited by the MAA? The report recommends more and better training for junior ranks, but completely fails to address the BIG one. Who made a false declaration when signing the Releases to Service for multiple platforms (not just Hawk) to the effect he was satisfied the Safety Case audit trail was complete and valid? Are those Stars, and those who briefed them, competent? Do THEY need retraining? Or trained in the first place? In other words, juniors are crucified but, YET AGAIN, senior staffs are not mentioned.
It rightly mentions RAFAT failures, but in my opinion dwells on them and draws the readers attention away from the organisational and systemic stuff. That is, it actively protects the senior staffs who KNOWINGLY allowed this to happen. Can we trust the MAA to correct this? Not a chance. They haven't bothered until now. Why? They're part of the problem because they dare not criticise their own MoD seniors. Which contrasts with Sqn Ldr Turner's brave statement (even if unguarded).
I wonder if Wg Cdr Spry has anything to say? Or is he still grappling with the concept of functional safety? This was a functional safety failure, but not according to Spry's definition. Come on, buck up, people are dying.
I, too, am with Sqn Ldr Turner on this one. The SI report details some poor lapses at RAFAT but what it actually describes is very serious and criminal SYSTEMIC and ORGANISATIONAL failures. Same as all the other cases we discuss here.
The way it is written is appalling. But, like many such reports, the feeling is there was much more and it has been heavily edited. You know, because MoD doesn't ensure it is consistent and makes sense, post-edit. (See ZD576 - we've been here before). Like many reports, it presents uninformed personal opinions as fact, while ignoring demonstrable fact. (See XV650/704 - we've been here before....).
The purpose of the SI is to identify causes and help prevent recurrence, but there is absolutely no depth to the engineering investigation whatsoever. It may look like there is; lots of diagrams of nuts, bolts and shackles, but this is basic, first year apprentice stuff. Pilots may topple or even be impressed, but engineers cringe. But if you list all the components of the process involved in ensuring that seat is safe, and used safely, then it barely touches most of them. I've said before, part of the reason is because MoD simply don't "do" this discipline anymore. 20 years after the Chinook safety case warning, which developed after the RAF Chief Engineer stopped such work, here we are with a safety critical system with no safety case. That is not the fault of RAFAT in any way, yet it is THE major failing because it is so fundamental everything else is affected. In case the MAA claim they haven't had enough time to correct this, the more recent Nimrod case was not a revelation, it was wholly predicted and advised to senior staffs and Ministers repeatedly over that 20 year period. The MAA INHERITED 20 years of very detailed and precise warnings, which time after time have been proven absolutely correct. But they say their clock started when they were formed, as if Haddon-Cave was a surprise. All he did was collate 20 years worth of recommendations, which were sat on the desks of various 3 and 4 Stars.
Regarding the laughably incompetent and criminal lack of a seat safety case. Having discovered that (well done the SI; it is the obvious question but so few ask it) then a significant portion of the report should have been aimed at WHY. Instead, it just moves on as if it is insignificant. I wonder if this part was edited by the MAA? The report recommends more and better training for junior ranks, but completely fails to address the BIG one. Who made a false declaration when signing the Releases to Service for multiple platforms (not just Hawk) to the effect he was satisfied the Safety Case audit trail was complete and valid? Are those Stars, and those who briefed them, competent? Do THEY need retraining? Or trained in the first place? In other words, juniors are crucified but, YET AGAIN, senior staffs are not mentioned.
It rightly mentions RAFAT failures, but in my opinion dwells on them and draws the readers attention away from the organisational and systemic stuff. That is, it actively protects the senior staffs who KNOWINGLY allowed this to happen. Can we trust the MAA to correct this? Not a chance. They haven't bothered until now. Why? They're part of the problem because they dare not criticise their own MoD seniors. Which contrasts with Sqn Ldr Turner's brave statement (even if unguarded).
I wonder if Wg Cdr Spry has anything to say? Or is he still grappling with the concept of functional safety? This was a functional safety failure, but not according to Spry's definition. Come on, buck up, people are dying.
DD:-
There I'm afraid we part company, because every airworthiness related military air accident that isn't tagged as such by the SI is another victory for the Star Chamber, whose principal purpose is to protect its members, in this case those who were directly responsible for the destruction of military airworthiness provision and those who were directly involved in covering that up.
The losers of course are everyone else, those who died in these avoidable accidents, their loved ones condemned to a lifetime of grief, those yet to die and those yet to grieve, those left behind to deal with this dysfunction, and the great unwashed British Public (self included) that go on paying for this needless waste of resource.
Someone somewhere has to stand up and say enough is enough, and this has got to stop, now! The solution has been laid down on this forum for years now, and it is simple enough. Remove the MAA and the MAAIB from the MOD and from each other. Head both up with civvie DGs, man with detached Service Personnel, and scour the earth for those who were around when this stuff worked and know how to make it work again. That means seeing Haddon Cave's Report for the sham that it was; ignoring evidence of illegal orders and actions in what it disingenuously called "A Golden Period of Airworthiness". Goebbels, eat your heart out!
THERE ARE NO WINNERS
The losers of course are everyone else, those who died in these avoidable accidents, their loved ones condemned to a lifetime of grief, those yet to die and those yet to grieve, those left behind to deal with this dysfunction, and the great unwashed British Public (self included) that go on paying for this needless waste of resource.
Someone somewhere has to stand up and say enough is enough, and this has got to stop, now! The solution has been laid down on this forum for years now, and it is simple enough. Remove the MAA and the MAAIB from the MOD and from each other. Head both up with civvie DGs, man with detached Service Personnel, and scour the earth for those who were around when this stuff worked and know how to make it work again. That means seeing Haddon Cave's Report for the sham that it was; ignoring evidence of illegal orders and actions in what it disingenuously called "A Golden Period of Airworthiness". Goebbels, eat your heart out!
Join Date: Apr 2004
Location: Erehwon
Posts: 1,146
Likes: 0
Received 0 Likes
on
0 Posts
The NO WINNERS I was referring to were the guys most definitely at the 'sharp end' both aircrew and engineering.
My question would be (if we're looking at the bigger picture), by what mechanism is it possible for some of your customers, rather than ALL your customers, to be unaware of a known directly safety-related problem.
Either:
a) Some other agency was told and did nothing about forwarding it.
b) The customer was told and that information was 'filtered'.
c) The customer was never told because the update/amendment service was not in place or efficient.
I did not notice that actually being addressed by the SI (although it's possible I missed it, as there are a lot of words).
Not sure the fat-lady has finished yet, but I've been wrong before . . .
My question would be (if we're looking at the bigger picture), by what mechanism is it possible for some of your customers, rather than ALL your customers, to be unaware of a known directly safety-related problem.
Either:
a) Some other agency was told and did nothing about forwarding it.
b) The customer was told and that information was 'filtered'.
c) The customer was never told because the update/amendment service was not in place or efficient.
I did not notice that actually being addressed by the SI (although it's possible I missed it, as there are a lot of words).
Not sure the fat-lady has finished yet, but I've been wrong before . . .
DD
In a previous post I explained the process by which MoD is informed. I'd lay money they were.
Things have indeed changed over the years. Not the process itself; that is still mandated. But nowadays it simply isn't funded and no-one is trained in its use. The last time I was asked to talk to an IPT about it (i.e. maintaining the Build Standard and Safety Case), in 2002, almost to a man they shouted "Waste of money"; because that is what they had been taught. The exception was an old lag who had worked in, surprise surprise, Directorate of Air Armament. And the only procedural Defence Standard laying down what to do was cancelled about 5 years ago, without replacement. Implementation must be very fragmented today.
The SI seem to have asked the PTs about a warning issued in 1991. The PTs, a new name for IPTs, didn't exist then. They will say, truthfully but disingenuously, "We don't have it". But that is not the same as "Martin Baker didn't provide it" - which is not actually claimed in the report. It has been implied and inferred; and MoD is quite happy with this. They asked the wrong people. What I can't understand is MB's silence. My guess is, because MoD do not operate a closed loop, there is no evidence of an acknowledgement of receipt; so they (MB) have been advised to say nothing.
Personally, I've been round this buoy before, on Mull of Kintyre. In about 2005 I asked a question via my MP. Minister told him my question was "Too technically difficult" and that MoD had no staff with the competence or knowledge to answer it. (A hell of an admission, but what this actually meant was their "Mull Team" was by now admin staff, and they were under instructions not to open the Box called "airworthiness". Their default position was denial). That involved a similar scenario - a document trail that should have existed between Company (Smiths Industries in that case) and MoD which would debunk one of MoD's main claims on MoK. My reply, via MP, was to give them the name, address and phone number of the guy at Smiths who would have the document. MoD toppled. As I've said before, they have form in these matters.
In a previous post I explained the process by which MoD is informed. I'd lay money they were.
Things have indeed changed over the years. Not the process itself; that is still mandated. But nowadays it simply isn't funded and no-one is trained in its use. The last time I was asked to talk to an IPT about it (i.e. maintaining the Build Standard and Safety Case), in 2002, almost to a man they shouted "Waste of money"; because that is what they had been taught. The exception was an old lag who had worked in, surprise surprise, Directorate of Air Armament. And the only procedural Defence Standard laying down what to do was cancelled about 5 years ago, without replacement. Implementation must be very fragmented today.
The SI seem to have asked the PTs about a warning issued in 1991. The PTs, a new name for IPTs, didn't exist then. They will say, truthfully but disingenuously, "We don't have it". But that is not the same as "Martin Baker didn't provide it" - which is not actually claimed in the report. It has been implied and inferred; and MoD is quite happy with this. They asked the wrong people. What I can't understand is MB's silence. My guess is, because MoD do not operate a closed loop, there is no evidence of an acknowledgement of receipt; so they (MB) have been advised to say nothing.
Personally, I've been round this buoy before, on Mull of Kintyre. In about 2005 I asked a question via my MP. Minister told him my question was "Too technically difficult" and that MoD had no staff with the competence or knowledge to answer it. (A hell of an admission, but what this actually meant was their "Mull Team" was by now admin staff, and they were under instructions not to open the Box called "airworthiness". Their default position was denial). That involved a similar scenario - a document trail that should have existed between Company (Smiths Industries in that case) and MoD which would debunk one of MoD's main claims on MoK. My reply, via MP, was to give them the name, address and phone number of the guy at Smiths who would have the document. MoD toppled. As I've said before, they have form in these matters.
Gentleman Aviator
Due to their somewhat unique role, this may or may not be acceptable to Duty Holders further up the food chain
For most of my regular career and still quite a bit now as a reservist, I've been involved in the writing of regulations, both flying and otherwise. In the military context, they are always - at one level or another - "our" regulations.
If they are inappropriate for a specialist unit, then change 'em. I'm not competent to judge whether RAFAT needs the CT that a 100 Sqn shag needs, but IF (a very big IF) RAFAT needs less, or can (sensibly and safely) double count sim slots, then it's hardly rocket science for the Regs to say: "Except RAFAT, see Annex X for their requirements."
I always used to say that Regulations shouldn't be broken - not from a dictatorial standpoint, but from the (to me) common sense one that if the Regs are unfit for purpose - then get them changed (with appropriate staff justification).
If they ARE fit for purpose - then bl%%dy well comply.
Join Date: Mar 2007
Location: Bristol Temple Meads
Posts: 869
Likes: 0
Received 0 Likes
on
0 Posts
What is all this talk about 1.5 threads showing, and pointless use of feeler gauges? The following is an extract from a MB Special Information Leaflet (SIL), issued in December 2013. It superseded a SIL issued in November 2011, which contained the same information exept the feeler guage check.
Why wasn't this information brought out by the SI or inquset? What steps have been taken to ensure this vital piece of information is reflected in the current maintenance procedures for ALL Mk10 seats.
DV
Maintenance Check of the Drogue Shackle connection to the Scissor Shackle (Refer to figures 1 & 3).
a) Ensure that the Seat has been made SAFE FOR MAINTENANCE.
b) Cut the No.8 parachute thread which passes through the Drogue Shackle and remove.
c) Ensure the first thread of the bolt is flush with the top face of the nut with just the dome protruding (as shown in figure 3b). If the nut is not correct as detailed, complete the procedure in item 2.2.
d) Lift the Scissor Shackle and ensure a 0.030" (or 0.75mm) feeler gauge can be inserted to contact the securing bolt as shown in figure 3b.
e) If the Drogue Shackle passes the gauge check and the first thread of the bolt is flush with the top face of the nut with just the dome protruding, install a new length of No.8 parachute thread to secure the Drogue Shackle in accordance with the relevant Technical Publication.
f) Complete all other necessary procedures detailed in the relevant Technical Publications to return the seat to operational use.
g) Record the satisfactory completion of this instruction on all relevant documentation
a) Ensure that the Seat has been made SAFE FOR MAINTENANCE.
b) Cut the No.8 parachute thread which passes through the Drogue Shackle and remove.
c) Ensure the first thread of the bolt is flush with the top face of the nut with just the dome protruding (as shown in figure 3b). If the nut is not correct as detailed, complete the procedure in item 2.2.
d) Lift the Scissor Shackle and ensure a 0.030" (or 0.75mm) feeler gauge can be inserted to contact the securing bolt as shown in figure 3b.
e) If the Drogue Shackle passes the gauge check and the first thread of the bolt is flush with the top face of the nut with just the dome protruding, install a new length of No.8 parachute thread to secure the Drogue Shackle in accordance with the relevant Technical Publication.
f) Complete all other necessary procedures detailed in the relevant Technical Publications to return the seat to operational use.
g) Record the satisfactory completion of this instruction on all relevant documentation
DV
Last edited by Distant Voice; 25th Feb 2014 at 12:40.
Deliverance
I think you need to be more specific about 'the leadership' and the responsibility for sharp-pencilling. From my reading of the SI this is about procedural drift and it is quite possible, or even probable, that the 'cure' for the stats shortfall started at junior level, ie with individual pilots, as a means of getting the job done. It may even have started with a previous Red 1 condoning or starting the practice years ago, as he would have had the same problem himself; I don't know this for a fact, and neither do you. But there was no evidence revealed by the SI that showed people further up the chain were aware or approved of what was being done.
Before the usual suspects wave conspiracy theories and VSO protectionism at me, I would suggest that it is perfectly possible for this situation to arise on almost any outfit you can name without the need for collusion from above. From my own recollections of supervising flying (FJ, BFT and ME) I would check that people had logged their CT requirements and particularly that sims were being done. The usual ops room currency-tracking boards helped with this. What I didn't do - because nobody had ever suggested it was necessary - was to cross-check with the records held by the sim. Nor did I conduct audits to check that the sim staff were logging things properly. Instead, I assumed (perhaps naively) that when someone made an entry in the auth sheets or their log book and signed for it, that they were being truthful and had done what was being claimed - it's called integrity and professionalism.
But TH is right: if you can't achieve a particular CT requirement on a regular basis because of a time or resource issue, then you need to flag it to the next level and ask for a change or a waiver. The 'leadership' can then examine the risk and decide whether to accept it or not.
I think you need to be more specific about 'the leadership' and the responsibility for sharp-pencilling. From my reading of the SI this is about procedural drift and it is quite possible, or even probable, that the 'cure' for the stats shortfall started at junior level, ie with individual pilots, as a means of getting the job done. It may even have started with a previous Red 1 condoning or starting the practice years ago, as he would have had the same problem himself; I don't know this for a fact, and neither do you. But there was no evidence revealed by the SI that showed people further up the chain were aware or approved of what was being done.
Before the usual suspects wave conspiracy theories and VSO protectionism at me, I would suggest that it is perfectly possible for this situation to arise on almost any outfit you can name without the need for collusion from above. From my own recollections of supervising flying (FJ, BFT and ME) I would check that people had logged their CT requirements and particularly that sims were being done. The usual ops room currency-tracking boards helped with this. What I didn't do - because nobody had ever suggested it was necessary - was to cross-check with the records held by the sim. Nor did I conduct audits to check that the sim staff were logging things properly. Instead, I assumed (perhaps naively) that when someone made an entry in the auth sheets or their log book and signed for it, that they were being truthful and had done what was being claimed - it's called integrity and professionalism.
But TH is right: if you can't achieve a particular CT requirement on a regular basis because of a time or resource issue, then you need to flag it to the next level and ask for a change or a waiver. The 'leadership' can then examine the risk and decide whether to accept it or not.
Before the usual suspects wave conspiracy theories and VSO protectionism at me
As these "usual suspects" have been 100% correct so far, on a number of accidents, I know who my money is on.
Distant Voice - excellent. If I read that correctly, the 1.5 thread advice has been abandoned? Does it tell users to fit a NEW nut?
I agree with Sir Peter; the discussion regarding the threads and clearances appear way back in this thread, albeit confused by those who thought they were doing it correctly when, as we now know, they were not.
Sir Peter
If so, I'd be grateful for a steer please. Like DV, I had read previous posts about feeler gauges not being appropriate and 1.5 threads showing, but it seems that immediately after the accident a special information leaflet was issued that contradicts this. Therefore, it looks like DV's question about whether this leaflet was revealed to the SI and Coroner is perfectly valid. And would the SI not be duty bound to ask why the discrepancy? A reasonable question IMO.
If so, I'd be grateful for a steer please. Like DV, I had read previous posts about feeler gauges not being appropriate and 1.5 threads showing, but it seems that immediately after the accident a special information leaflet was issued that contradicts this. Therefore, it looks like DV's question about whether this leaflet was revealed to the SI and Coroner is perfectly valid. And would the SI not be duty bound to ask why the discrepancy? A reasonable question IMO.
SPHL & JTO
With respect, I don't think it is DV or Dervish who is confused. The SIL noted by DV was issued AFTER the accident, and amended just a couple of months ago. This is not the "missing" information from 1991 MoD claimed it could not find.
To answer a previous question, yes it says a new nut must be used.
The obvious questions are;
1. Why was this 2011/2013 SIL not mentioned by the SI or at the inquest?
2. What instructions does it replace? That is, do the previous instructions call for a feeler guage test, a new nut, a manual freedom of movement check and the nut to be flush with the end of the bolt?
This comparison, and understanding the difference between old and new procedures, it absolutely vital. Clearly, the SI has been deliberately misled. Or, if they were given this SIL and omitted to mention it, they are equally as guilty as the VSOs who directed that such maintenance data should not be included in ATPs. Either way, they (SI and Inquest) took a direction that would have been very different had the SIL been mentioned.
By the way, last week I spoke to the head of Tech Pubs at the time. Before you ask, no, the SI didn't bother to make the phone call, despite him being VERY well known to MoD for a number of reasons. He confirms the standard Publications clauses, and hence Publications Management Plans of the day, mandated a "Common Source Database of all technical information applicable to the system". The Plan is very specific about (in this case) Martin Baker's obligation to update MoD pubs and inform (in this case) BAeS.
But, and it is a big BUT, this assumes MB were under proper contract and properly funded. This is doubtful because, as stated before, the RAF Chief Engineer had set about chopping all funding for this, and by January 1993 had decreed no tech pubs amendments would be funded, not even safety related amendments. This applied to Fault Investigations and Unsatisfactory Feature Reports, and all other components of the Build Standard. When this fact is mentioned in a report or at an inquest, I'll think about amending my factual statement about VSOs being protected! But the fact remains, these quite deliberate cuts were made, they were concealed from various inquiries by MoD, whose denials only ceased when original copies of the policies were submitted to Lord Philip. Why lie? To conceal the truth. They no longer lie about it; they just mislead by omission and commission. But many would say this is tantamount to lying, especially when people are dying. Either way, it is a grave offence, yet openly condoned by DE&S, the MAA and Ministers.
With respect, I don't think it is DV or Dervish who is confused. The SIL noted by DV was issued AFTER the accident, and amended just a couple of months ago. This is not the "missing" information from 1991 MoD claimed it could not find.
To answer a previous question, yes it says a new nut must be used.
The obvious questions are;
1. Why was this 2011/2013 SIL not mentioned by the SI or at the inquest?
2. What instructions does it replace? That is, do the previous instructions call for a feeler guage test, a new nut, a manual freedom of movement check and the nut to be flush with the end of the bolt?
This comparison, and understanding the difference between old and new procedures, it absolutely vital. Clearly, the SI has been deliberately misled. Or, if they were given this SIL and omitted to mention it, they are equally as guilty as the VSOs who directed that such maintenance data should not be included in ATPs. Either way, they (SI and Inquest) took a direction that would have been very different had the SIL been mentioned.
By the way, last week I spoke to the head of Tech Pubs at the time. Before you ask, no, the SI didn't bother to make the phone call, despite him being VERY well known to MoD for a number of reasons. He confirms the standard Publications clauses, and hence Publications Management Plans of the day, mandated a "Common Source Database of all technical information applicable to the system". The Plan is very specific about (in this case) Martin Baker's obligation to update MoD pubs and inform (in this case) BAeS.
But, and it is a big BUT, this assumes MB were under proper contract and properly funded. This is doubtful because, as stated before, the RAF Chief Engineer had set about chopping all funding for this, and by January 1993 had decreed no tech pubs amendments would be funded, not even safety related amendments. This applied to Fault Investigations and Unsatisfactory Feature Reports, and all other components of the Build Standard. When this fact is mentioned in a report or at an inquest, I'll think about amending my factual statement about VSOs being protected! But the fact remains, these quite deliberate cuts were made, they were concealed from various inquiries by MoD, whose denials only ceased when original copies of the policies were submitted to Lord Philip. Why lie? To conceal the truth. They no longer lie about it; they just mislead by omission and commission. But many would say this is tantamount to lying, especially when people are dying. Either way, it is a grave offence, yet openly condoned by DE&S, the MAA and Ministers.
Join Date: Dec 2000
Location: UK
Posts: 737
Likes: 0
Received 0 Likes
on
0 Posts
I had read previous posts about feeler gauges not being appropriate
1.5 threads showing
immediately after the accident a special information leaflet was issued that contradicts this
The MB SILs were issued after the accident