Flt. Lt. Sean Cunningham inquest
JTO
Agreed, and no-one is saying otherwise. But that was over two years ago and the inquest was only last month. And the SI report is dated 15th May 2013, 18 months after the SIL and accident. So why does it not mention it and compare it with previous instructions? The SI report goes into this aspect in great detail, so the SIL is a startling omission. It would answer many questions, in addition to demonstrating a process exists for MoD receiving information from MB. But, of course, admitting that would call into question the notion that previous instructions were not received, opening Pandora's Box.
Not disagreeing with you, just looking at it from an angle I am familiar with.
Agreed, and no-one is saying otherwise. But that was over two years ago and the inquest was only last month. And the SI report is dated 15th May 2013, 18 months after the SIL and accident. So why does it not mention it and compare it with previous instructions? The SI report goes into this aspect in great detail, so the SIL is a startling omission. It would answer many questions, in addition to demonstrating a process exists for MoD receiving information from MB. But, of course, admitting that would call into question the notion that previous instructions were not received, opening Pandora's Box.
Not disagreeing with you, just looking at it from an angle I am familiar with.
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The MB SILs were issued after the accident
DV
Sir Peter
Post 554.
I cannot disagree with the poster's information, but the conflict intrigues me.
As for the bolt and threads, again there is an apparent conflict. Until now everyone's been talking about 1.5 threads, yet an instruction is now issued saying there should be no thread showing. Big difference and I just wondered if this was revealed to the SI or coroner. You say "unless otherwise stated", but should it not be established when what was stated? And why it has changed?
Post 554.
I cannot disagree with the poster's information, but the conflict intrigues me.
As for the bolt and threads, again there is an apparent conflict. Until now everyone's been talking about 1.5 threads, yet an instruction is now issued saying there should be no thread showing. Big difference and I just wondered if this was revealed to the SI or coroner. You say "unless otherwise stated", but should it not be established when what was stated? And why it has changed?
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The SI & Coroner investigation timelines end on the day of the accident. Or more accurately, they start there, and then go backwards!
MB had their investigation nailed in a few days and reacted accordingly.
The SI & Coroner did know about the scissor shackle, it is all over the reports!
MB had their investigation nailed in a few days and reacted accordingly.
The SI & Coroner did know about the scissor shackle, it is all over the reports!
The SI & Coroner did know about the scissor shackle, it is all over the reports!
Try as I might, I can't find a reference to the SIL in the SI report.
Please supply a quote
If it isn't mentioned, then what they say about the scissor shackle assembly is incomplete and misleading.
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(posts crossing again, caught in a time warp)
It was not in the procedure. The SI deals with this, and so does the Coroner - this is why the Coroner said that no engineers were to blame.
but should it not be established when what was stated? And why it has changed?
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SI page 68 Aggravating Factors
1.4.7.3
a. The extant publications and guidance for fitment of the drogue and scissor shackle
More detail at 1.4.3.12
b. Poor communication between DE&S, Industry and User...etc
More detail at 1.4.4.2
c. The dimensions of the drogue shackle components...etc
More detail at 1.4.4.3
1.4.7.3
a. The extant publications and guidance for fitment of the drogue and scissor shackle
More detail at 1.4.3.12
b. Poor communication between DE&S, Industry and User...etc
More detail at 1.4.4.2
c. The dimensions of the drogue shackle components...etc
More detail at 1.4.4.3
I think the point being made is one I made earlier. The SI correctly reports these factors/failings, but does not explore underlying reasons; negligent in the extreme given they all fall into the category "FFS, not again!" The uninformed reader (most of MoD and, to a lesser extent, Joe Public), would infer this is all a revelation, confined to Hawk, when in fact it has all been formally reported over many years, applies pan-MoD, and a deliberate decision made not to address it. That is, knowingly place aircrew in danger.
To repeat another question; if it is not the SI's job to understand what it is saying, then who? Not the MAA, apparently. They know the answers, but won't admit them; partly because knowing and understanding are two different things, partly because the facts directly implicate too many VSOs. The MAA's endorsement of the report, without explaining these factors, is a gross failure. What example does this set to those junior DE&S staffs charged with this, the most responsible of tasks?
To repeat another question; if it is not the SI's job to understand what it is saying, then who? Not the MAA, apparently. They know the answers, but won't admit them; partly because knowing and understanding are two different things, partly because the facts directly implicate too many VSOs. The MAA's endorsement of the report, without explaining these factors, is a gross failure. What example does this set to those junior DE&S staffs charged with this, the most responsible of tasks?
tuc:-
Here we are getting to the nub of things. The SI discovers what caused this accident, ie the death of Sean Cunningham, yet its Report does not ascribe to it as such, merely that it was a contributory cause. What they discover is that cause, an overtightened shackle bolt, was a hazard highlighted by the manufacturer decades earlier, yet the UK military airworthiness authority professes no knowledge of it. So a life critical aircraft system, its escape system, is rendered unairworthy and kills, all because all that the engineers have to hand is a generic practice (1.5 threads showing) that does not prevent this unairworthiness. The seat doesn't even have a Safety Case!
All these failings are known of by the SI, yet its Report offers the seat pan handle pin (in/out?) ambiguity as the cause of the accident (ie the death of Flt Lt Cunningham), and is commended for it by the DG Military Aviation Authority responsible for UK Military Airworthiness. This reeks of cover up and Star Chamber intervention. Once again we see a military air accident investigation has been compromised from above. Same old same old.
Self Regulation Doesn't Work and in Aviation it Kills!
The SI correctly reports these factors/failings, but does not explore underlying reasons
All these failings are known of by the SI, yet its Report offers the seat pan handle pin (in/out?) ambiguity as the cause of the accident (ie the death of Flt Lt Cunningham), and is commended for it by the DG Military Aviation Authority responsible for UK Military Airworthiness. This reeks of cover up and Star Chamber intervention. Once again we see a military air accident investigation has been compromised from above. Same old same old.
Self Regulation Doesn't Work and in Aviation it Kills!
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Tuc, Chug, Others,
Not wanting to disagree, but just hoping to clarify.
Having ploughed through the SI report again, I am struck by the uneven quality of the document and the layout. I fully understand why people reading it are confused and unclear over how its findings relate to what appears to have happened.
The report sets out on Page 1 of Part 1.4 how it is going to group its 'accident factors': cause, contributory, aggravating, other, and finally observations. I can see their logic that separates a 'contributory' from an 'aggravating' factor. I don't think it's especially helpful, and in this case makes it harder to grasp the accident 'chain'.
Here's my take, for what it's worth.
The 'accident' was the death of the pilot. It was caused by an inadvertent ejection, followed by malfunction of the drogue and scissor shackle assembly. Years ago, these two factors might have been called 'primary' and 'secondary' causes.
Like any accident, they lie within a longer and often complex chain of events. A good report sets out how that chain came into existence, and what triggered the sequence. I honestly don't think that this report does that especially well. I can see why the SI sets its findings out differently, but my opinion (and that's all it is) is that they have followed process at the expense of clarity.
Anyway, that's my take.
I agree that the SI does not do enough to follow up why information got lost, and what happened to the normal airworthiness management functions. The lack of documentation of the relevant 22 Gp/PT meetings, lack of hazard reporting, and general lack of grip of the process is just astonishing, and I would put it as much, much higher up the chain that an 'other' factor. (I agree with Tuc that it is highly probable that MB told the MoD about the shackle issues at some stage, and that the information dropped down the MoD's organisational cracks). The lack of a seat Safety Case has to be a huge worry for DE&S - why didn't the DE&S assurance processes pick that up? What's happened to internal QA? What happened to the PT's ISA?
Then we get to the next level up: Where was the MAA's 'Oversight' Division? What about MAA 'Surveillance'? When was the last MAA audit of the PTs?
I suppose this is where I meet Tuc's main concerns - how does the system ensure that those questions get properly asked? I think it's clear that you can have the biggest and shiniest set of regulations (and regulators), but they mean nothing if they aren't actually being implemented.
Hope this helps, best regards as ever to those picking up the pieces
Engines
Not wanting to disagree, but just hoping to clarify.
Having ploughed through the SI report again, I am struck by the uneven quality of the document and the layout. I fully understand why people reading it are confused and unclear over how its findings relate to what appears to have happened.
The report sets out on Page 1 of Part 1.4 how it is going to group its 'accident factors': cause, contributory, aggravating, other, and finally observations. I can see their logic that separates a 'contributory' from an 'aggravating' factor. I don't think it's especially helpful, and in this case makes it harder to grasp the accident 'chain'.
Here's my take, for what it's worth.
The 'accident' was the death of the pilot. It was caused by an inadvertent ejection, followed by malfunction of the drogue and scissor shackle assembly. Years ago, these two factors might have been called 'primary' and 'secondary' causes.
Like any accident, they lie within a longer and often complex chain of events. A good report sets out how that chain came into existence, and what triggered the sequence. I honestly don't think that this report does that especially well. I can see why the SI sets its findings out differently, but my opinion (and that's all it is) is that they have followed process at the expense of clarity.
Anyway, that's my take.
I agree that the SI does not do enough to follow up why information got lost, and what happened to the normal airworthiness management functions. The lack of documentation of the relevant 22 Gp/PT meetings, lack of hazard reporting, and general lack of grip of the process is just astonishing, and I would put it as much, much higher up the chain that an 'other' factor. (I agree with Tuc that it is highly probable that MB told the MoD about the shackle issues at some stage, and that the information dropped down the MoD's organisational cracks). The lack of a seat Safety Case has to be a huge worry for DE&S - why didn't the DE&S assurance processes pick that up? What's happened to internal QA? What happened to the PT's ISA?
Then we get to the next level up: Where was the MAA's 'Oversight' Division? What about MAA 'Surveillance'? When was the last MAA audit of the PTs?
I suppose this is where I meet Tuc's main concerns - how does the system ensure that those questions get properly asked? I think it's clear that you can have the biggest and shiniest set of regulations (and regulators), but they mean nothing if they aren't actually being implemented.
Hope this helps, best regards as ever to those picking up the pieces
Engines
Careful Engines. With posts like that you’ll be labelled a “usual suspect” for advocating safety on an aviation forum!
If I may take one point. Oversight. MoD has been criticised before for lack of oversight. On Nimrod MRA4, which was cancelled because the aircraft could never be “certified” (Hammond, House of Commons 3rd Feb 2014), the Public Accounts Committee confirmed a “lack of management oversight”, with MoD claiming the individual could not be identified. (See Management Plans or Staff Lists of the day. It was Director General Air Systems 2, which about 3000 people at AbbeyWood could have told the PAC). This individual upheld disciplinary action against civilians for refusing to obey orders to ignore airworthiness and financial probity regulations, and directed that aircraft need not be functionally safe when delivered but a declaration could be made that they were. Ministers upheld his rulings and DE&S continue to do so. In other words, it would have been mighty inconvenient for him to be named.
A similar scenario exists within the MAA. What if, for example, a former IPT leader, responsible for delivering and maintaining the Safety Case, is now a senior officer in the MAA when an audit is ordered? The audit reveals it hasn’t been maintained for about 20 years and, therefore, the RTS has become progressively invalid and unrepresentative. And there is a raft of evidence to prove it. Oh, and dozens have died while the aircraft was unairworthy, and the recommendations of a major report remain unactioned for those 20 years. Does the senior officer declare a conflict of interest? Does he seek a move from the MAA? No; what happens is nothing is said and he continues his so-called oversight role, even advising Ministers. Yet, highlighting this gross failure and accepting it for what it was – a systemic failure affecting all MoD – would have helped prevent subsequent accidents. Perhaps Sean Cunningham might have been killed anyway, one can never say; but there would have been a Safety Case and the failure to implement servicing instructions would have been flagged. His defences in depth would have been more intact. Can we have any confidence in such a system? How to avoid it? A truly independent MAA.
Then we get to the next level up: Where was the MAA's 'Oversight' Division? What about MAA 'Surveillance'? When was the last MAA audit of the PTs?
If I may take one point. Oversight. MoD has been criticised before for lack of oversight. On Nimrod MRA4, which was cancelled because the aircraft could never be “certified” (Hammond, House of Commons 3rd Feb 2014), the Public Accounts Committee confirmed a “lack of management oversight”, with MoD claiming the individual could not be identified. (See Management Plans or Staff Lists of the day. It was Director General Air Systems 2, which about 3000 people at AbbeyWood could have told the PAC). This individual upheld disciplinary action against civilians for refusing to obey orders to ignore airworthiness and financial probity regulations, and directed that aircraft need not be functionally safe when delivered but a declaration could be made that they were. Ministers upheld his rulings and DE&S continue to do so. In other words, it would have been mighty inconvenient for him to be named.
A similar scenario exists within the MAA. What if, for example, a former IPT leader, responsible for delivering and maintaining the Safety Case, is now a senior officer in the MAA when an audit is ordered? The audit reveals it hasn’t been maintained for about 20 years and, therefore, the RTS has become progressively invalid and unrepresentative. And there is a raft of evidence to prove it. Oh, and dozens have died while the aircraft was unairworthy, and the recommendations of a major report remain unactioned for those 20 years. Does the senior officer declare a conflict of interest? Does he seek a move from the MAA? No; what happens is nothing is said and he continues his so-called oversight role, even advising Ministers. Yet, highlighting this gross failure and accepting it for what it was – a systemic failure affecting all MoD – would have helped prevent subsequent accidents. Perhaps Sean Cunningham might have been killed anyway, one can never say; but there would have been a Safety Case and the failure to implement servicing instructions would have been flagged. His defences in depth would have been more intact. Can we have any confidence in such a system? How to avoid it? A truly independent MAA.
As someone whose knowledge of ejection seats ceased after working on the Lightning on 92 Sqn ask a question in order to get my feeble mind round the whole sad business ?
Was the seat 'unairworthy' within the definition as outlined by tucumseh ?
What triggered the initiation of the seat ?
Was there a design error ?
Was their a servicing error ?
Yes I have read everything but am still confused !
One thing that strikes me about the revelations by tucumseh and others is how naive I (and I suspect many others) have been throughout my service career.
I always assume that those of us at the 'coal face' (aircrew and ground crew)
were having our best interests looked after by those further up the food chain.
The opposite now appears to have been the case. In the furtherance of awards, careers and penny pinching the very things that should have helped safeguard us have been discarded as irrelevent. And despite the charade that appears to be the MAA nothing will change. How these gentlemen can sleep at night is beyond me.
Was the seat 'unairworthy' within the definition as outlined by tucumseh ?
What triggered the initiation of the seat ?
Was there a design error ?
Was their a servicing error ?
Yes I have read everything but am still confused !
One thing that strikes me about the revelations by tucumseh and others is how naive I (and I suspect many others) have been throughout my service career.
I always assume that those of us at the 'coal face' (aircrew and ground crew)
were having our best interests looked after by those further up the food chain.
The opposite now appears to have been the case. In the furtherance of awards, careers and penny pinching the very things that should have helped safeguard us have been discarded as irrelevent. And despite the charade that appears to be the MAA nothing will change. How these gentlemen can sleep at night is beyond me.
Engines, while the uncommanded ejection came first, followed by the failure of the drogue to separate man from seat with a deployed chute, I still maintain that the accident (the death of the pilot) was caused by the latter and contributed to by the former.
The MOD (aka the MAAIB, aka the MAA) by presenting it as they did obscured the direct link to the malevolent sabotage of Airworthiness Provision in the "Golden Period". That is why there was no Safety Case, that is why they cannot trace the MB alert, that is why the shackle bolt was jammed in the scissor jaws, that is why Sean Cunningham died.
Even if we take their version, the inadvertent ejection was caused by a known design problem which others testify here to being made aware of, yet nothing was done to rectify it and it remained an accident waiting to happen. It was a danger to the aircraft occupant, ie the seat was unairworthy, and once again it did not have a Safety Case.
So Sean Cunningham's death was caused by an airworthiness related accident, under the auspices of the UK Military Airworthiness Authority which hasn't been fit for purpose since the late 80s. Enough testimony has been laid before us in PPRuNe Military Air Accident Threads to know why that is and what must be done to resolve it (separation of the MAA and MAAIB from the MOD and from each other). Time is of the essence, because more accidents and more deaths will follow until that resolution occurs. Avoidable accidents and needless deaths!
Self Regulation Doesn't Work, and in Aviation It Kills!
PS excellent post aa62, I hope I have answered some of your queries at least.
The MOD (aka the MAAIB, aka the MAA) by presenting it as they did obscured the direct link to the malevolent sabotage of Airworthiness Provision in the "Golden Period". That is why there was no Safety Case, that is why they cannot trace the MB alert, that is why the shackle bolt was jammed in the scissor jaws, that is why Sean Cunningham died.
Even if we take their version, the inadvertent ejection was caused by a known design problem which others testify here to being made aware of, yet nothing was done to rectify it and it remained an accident waiting to happen. It was a danger to the aircraft occupant, ie the seat was unairworthy, and once again it did not have a Safety Case.
So Sean Cunningham's death was caused by an airworthiness related accident, under the auspices of the UK Military Airworthiness Authority which hasn't been fit for purpose since the late 80s. Enough testimony has been laid before us in PPRuNe Military Air Accident Threads to know why that is and what must be done to resolve it (separation of the MAA and MAAIB from the MOD and from each other). Time is of the essence, because more accidents and more deaths will follow until that resolution occurs. Avoidable accidents and needless deaths!
Self Regulation Doesn't Work, and in Aviation It Kills!
PS excellent post aa62, I hope I have answered some of your queries at least.
Last edited by Chugalug2; 27th Feb 2014 at 09:38.
AA62
Good question, although I'd prefer to reference it against the MoD's definition and regulations. My job was simply to adhere to these regulations, mandated upon us in our letters of delegation (as amended by 2/3/4 Star instructions NOT to adhere to them!)
There was no seat Safety Case, therefore by definition the Whole Aircraft Safety Case for any aircraft fitted with this seat cannot be complete, validated or verified. It follows that the Release to Service, the Master Airworthiness Reference, is based on a false premise.
So much to consider, and so much regression to be undertaken. The regulations demand that many many MoD staff are currently beavering away on this regression. Eventually, they'll get to the Airworthiness Review Team reports of the 1990s and say "Oh crap, all this was known about. Why weren't the recommendations implemented?" And then the MAA DG will report to Minister or Secy of State and say "He told you so, and we told you to ignore him, and people died, and, oh crap........ we resign" OK, the last is wishful thinking.
Was the seat 'unairworthy' within the definition as outlined by tucumseh ?
Good question, although I'd prefer to reference it against the MoD's definition and regulations. My job was simply to adhere to these regulations, mandated upon us in our letters of delegation (as amended by 2/3/4 Star instructions NOT to adhere to them!)
There was no seat Safety Case, therefore by definition the Whole Aircraft Safety Case for any aircraft fitted with this seat cannot be complete, validated or verified. It follows that the Release to Service, the Master Airworthiness Reference, is based on a false premise.
So much to consider, and so much regression to be undertaken. The regulations demand that many many MoD staff are currently beavering away on this regression. Eventually, they'll get to the Airworthiness Review Team reports of the 1990s and say "Oh crap, all this was known about. Why weren't the recommendations implemented?" And then the MAA DG will report to Minister or Secy of State and say "He told you so, and we told you to ignore him, and people died, and, oh crap........ we resign" OK, the last is wishful thinking.
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Originally Posted by tucumseh
On Nimrod MRA4, which was cancelled because the aircraft could never be “certified” (Hammond, House of Commons 3rd Feb 2014),
I am in a discussion on the cancellation on another forum, and would love to have an official acknowledgement to further my case.
GK121 - It was after the Russian carrier Kuznetsov had sashayed gaily past Scotland while the Navy rushed up from Southern England (I think). The dread words MRA4 were never mentioned, but...... (Hansard 3 Feb 2014 : Column 4)
My bold
airsound
Revenons aux moutons, mes amis
Mr Kevan Jones (North Durham) (Lab):....... will the Secretary of State tell the House what he is going to do to plug the capability gap in maritime surveillance that has been created by his Government, apart from relying on Twitter?
It is a bit rich for him to say that the gap in maritime patrol cover was created by this Government. What this Government did was to recognise the reality that his Government had been investing in aircraft that would never fly, would never be certified and would never be able to deliver a capability.
airsound
Revenons aux moutons, mes amis
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Originally Posted by Chugalug2
I still maintain that the accident (the death of the pilot) was caused by the latter and contributed to by the former.
If I drove into the back of another car and was killed because my airbag failed to deploy, the accident was caused by me but I was killed as a result of the airbag failure. The airbag failure wasn't the accident.
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I'm with you Vendee
However, earlier on this thread, someone has pointed out that without Flt Lt Cunningham's death, the aircraft damage did not warrant a Service Inquiry (by the MoD's own definition)
However, earlier on this thread, someone has pointed out that without Flt Lt Cunningham's death, the aircraft damage did not warrant a Service Inquiry (by the MoD's own definition)
Green Knight
It was a reply to Kevan Jones MP (Lab) on that date.
"It is a bit rich for him to say that the gap in maritime patrol cover was created by this Government. What this Government did was to recognise the reality that his Government had been investing in aircraft that would never fly, would never be certified and would never be able to deliver a capability."
It was a reply to Kevan Jones MP (Lab) on that date.
"It is a bit rich for him to say that the gap in maritime patrol cover was created by this Government. What this Government did was to recognise the reality that his Government had been investing in aircraft that would never fly, would never be certified and would never be able to deliver a capability."
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SPHL,
It's my view (and that's all it is) that under the old RN rules where the Command decided whether or not to initiate a BoI, an uncommanded (or accidental) ejection would have led to a formal inquiry, supported by the AIU, even if the pilot had survived.
There was always an element of discretion available under that system, as I remember it. The FAA took ejection seat safety extremely seriously (like the RAF), and had a generally good record (like the RAF).
Personally, (and again I stress it's just my view) I am concerned at the way that the formation of the MAA has had the effect of taking a measure of responsibility for airworthiness and safety away from the Commands. It's certainly led to the situation where the 'decision level' has jumped two ranks upwards at least. Again, I don't think that's an entirely good idea - I think safety management works better the more people are involved and responsible.
Best Regards as ever to all those striving to stay safe and get the job done,
Engines
It's my view (and that's all it is) that under the old RN rules where the Command decided whether or not to initiate a BoI, an uncommanded (or accidental) ejection would have led to a formal inquiry, supported by the AIU, even if the pilot had survived.
There was always an element of discretion available under that system, as I remember it. The FAA took ejection seat safety extremely seriously (like the RAF), and had a generally good record (like the RAF).
Personally, (and again I stress it's just my view) I am concerned at the way that the formation of the MAA has had the effect of taking a measure of responsibility for airworthiness and safety away from the Commands. It's certainly led to the situation where the 'decision level' has jumped two ranks upwards at least. Again, I don't think that's an entirely good idea - I think safety management works better the more people are involved and responsible.
Best Regards as ever to all those striving to stay safe and get the job done,
Engines