Flt. Lt. Sean Cunningham inquest
Unlike the chicken and the egg, we know which came first here, but first doesn't necessarily mean cause. I agree with engines that the accident was the pilot's death, but the cause of that death was the failure of his parachute to deploy. The inadvertent ejection triggered the sequence that led to that cause, ie it contributed to it, but was not the cause of death.
Having said that, if any accidental ejection for whatever reason is now considered an accident per se, it rather muddies the waters. It also seems to conflict with the MAA definition of an accident, but no doubt discretion can be exercised, the question is by whom?
As others have said, this Report reads like a mangled schoolboy essay that the dog ate but then coughed up. It has revisionism written all over it. That is a problem shared with other BoI's and SI's featured in this forum. How can anyone take such a Report on trust? How do we know that the accident cause in the Report was even that found by the SI Panel? How can such a Report prevent future accidents if it can't be trusted? Do you trust it?
Having said that, if any accidental ejection for whatever reason is now considered an accident per se, it rather muddies the waters. It also seems to conflict with the MAA definition of an accident, but no doubt discretion can be exercised, the question is by whom?
As others have said, this Report reads like a mangled schoolboy essay that the dog ate but then coughed up. It has revisionism written all over it. That is a problem shared with other BoI's and SI's featured in this forum. How can anyone take such a Report on trust? How do we know that the accident cause in the Report was even that found by the SI Panel? How can such a Report prevent future accidents if it can't be trusted? Do you trust it?
Last edited by Chugalug2; 27th Feb 2014 at 22:26.
How do we know that the accident cause in the Report was even that found by the SI Panel? How can such a Report prevent future accidents if it can't be trusted? Do you trust it?
Not sure why some are continuing to doubt the 'cause' and 'contributory' ... one could argue it either way but the end result is still a tragic death !
My personal view is that the cause of the accident was the ejection,the cause of death was the chute failure but as I posted previously - the 2 definitions are very different.
The wider airworthiness issues are separate to the technical investigation and I will not comment on that since others on here are far more knowledgeable !
Longer Ron
I agree.
I disagree, although see your point. Airworthiness is an engineering discipline and the engineer(s) on the SI panel should understand the impact systemic failings had on their findings. Duty of Care demands they report this.
I accept the SI's terms of reference do not seem to extend to underlying causes, so would place the onus on the MAA, who are seen to endorse and issue the report.
The aim is to prevent recurrence. As it stands, the SI's investigation and report may help prevent recurrence of that specific event at RAFAT, perhaps on Hawk. But most definitely NOT in the wider MoD.
That is because the root cause is, as you say, a wider malaise. There will be other avoidable accidents, and like many before them will be easily traced to the decision not to maintain build standards, safety cases or have a compliant RTS.
That this was a quite conscious DECISION in order to save money and hide waste, not an oversight or mistake, is what people cannot grasp, or in the case of MoD do not want to grasp.
The technical investigation was carried out to an extremely high standard
The wider airworthiness issues are separate to the technical investigation
I accept the SI's terms of reference do not seem to extend to underlying causes, so would place the onus on the MAA, who are seen to endorse and issue the report.
The aim is to prevent recurrence. As it stands, the SI's investigation and report may help prevent recurrence of that specific event at RAFAT, perhaps on Hawk. But most definitely NOT in the wider MoD.
That is because the root cause is, as you say, a wider malaise. There will be other avoidable accidents, and like many before them will be easily traced to the decision not to maintain build standards, safety cases or have a compliant RTS.
That this was a quite conscious DECISION in order to save money and hide waste, not an oversight or mistake, is what people cannot grasp, or in the case of MoD do not want to grasp.
tuc, as usual, makes the point better than I. The MAA as guardian of UK Military Airworthiness Provision needs to see what perhaps individual SI's might fail to, the correlation between all these fatal airworthiness linked accidents leading way back into Haddon Cave's 'Golden Period'. It doesn't do that of course because its very purpose, the reason that it exists, is to ensure that correlation never happens. It is greatly assisted in that by the fortuitous arrangement whereby all SI's are carried out under its auspices by its subsidiary, the MilAAIB.
This SI has indeed found out the technical problems with this seat that killed Sean Cunningham. Job done? No, because those problems were already known of by the RAF and the Seat Manufacturer respectively, yet the UK Military Airworthiness Authority claims to have had no knowledge of the latter whatsoever. Really? Why was that? It was the subject of urgent promulgation by MB, yet its major customer professes to have never been informed. That is where any Air Accident Investigator worth its salt would home in on and uncover the whole rotten mess that is UK Military Airworthiness. Does the MilAAIB do so? No, because this SI just went through the motions, like most other UK Military Air Accident Investigations.
The MilAAIB might well sit within the MAA for they are well suited to each other, the words chocolate fireguards come to mind. This is a tragedy of enormous proportions for UK Military Aviation. It has to be put right lest many more needless deaths are to follow.
This SI has indeed found out the technical problems with this seat that killed Sean Cunningham. Job done? No, because those problems were already known of by the RAF and the Seat Manufacturer respectively, yet the UK Military Airworthiness Authority claims to have had no knowledge of the latter whatsoever. Really? Why was that? It was the subject of urgent promulgation by MB, yet its major customer professes to have never been informed. That is where any Air Accident Investigator worth its salt would home in on and uncover the whole rotten mess that is UK Military Airworthiness. Does the MilAAIB do so? No, because this SI just went through the motions, like most other UK Military Air Accident Investigations.
The MilAAIB might well sit within the MAA for they are well suited to each other, the words chocolate fireguards come to mind. This is a tragedy of enormous proportions for UK Military Aviation. It has to be put right lest many more needless deaths are to follow.
Last edited by Chugalug2; 28th Feb 2014 at 08:55.
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Chug,
I think I have to gently differ from you in what is probably a minor matter.In any case, I post this only to attempt to help others through the issues.
First, I agree with other posts that getting into semantics over the various factors that led to this tragic accident aren't especially helpful. Like almost all such events, there was a chain of causes and events and the SI's job was to find all the links in that chain and set out recommendations to prevent re-occurrence.
I think the technical investigation into the seat aspects was well done, and it's good to see the capability of the old NAML (Naval Aircraft Materials Laboratory - now 1710 NAS) and the professionalism of the old RN AIU (the cornerstone of the new MilAAIB) still delivering good results. The fact that they got 'folded' into the MAA following Haddon Cave wasn't their fault - and I very much agree that having them there is a basic mistake. However, i would gently offer that calling them a 'chocolate fireguard' is just a bit strong. I'm sure that they are doing the best they can within the organisation that they were given to work with. In fact, I know they are.
As I've posted, my own opinion is that the format adopted by the MAA for reports makes it harder for them to be clearly understood and acted upon. In this case, the technical factors were reasonably clear, but the organisational aspects were less clearly established. And that brings up to the issue of how far up the chain the SI can go in looking at the 'organisational' stuff. I agree with Tuc that the SI should have found out why the aircraft's Safety Case was so badly compromised. It should also have established why the airworthiness trail for the RTI (which is supposed to be auditable) was so thin.
But I don't think that any SI is going to be able to go back tens of years and look at funding and policy decisions by VSOs that contributed to the present situation. My own view is that the MoD has to be responsible, at all levels, for managing and preserving 'Air Safety', which includes airworthiness. That means people have to do their job. The basics haven't changed. What does bother me is that a number of managers within the system no longer have a clear idea of what 'the basics' involve.
Best Regards as ever to all those working the issues,
Engines
I think I have to gently differ from you in what is probably a minor matter.In any case, I post this only to attempt to help others through the issues.
First, I agree with other posts that getting into semantics over the various factors that led to this tragic accident aren't especially helpful. Like almost all such events, there was a chain of causes and events and the SI's job was to find all the links in that chain and set out recommendations to prevent re-occurrence.
I think the technical investigation into the seat aspects was well done, and it's good to see the capability of the old NAML (Naval Aircraft Materials Laboratory - now 1710 NAS) and the professionalism of the old RN AIU (the cornerstone of the new MilAAIB) still delivering good results. The fact that they got 'folded' into the MAA following Haddon Cave wasn't their fault - and I very much agree that having them there is a basic mistake. However, i would gently offer that calling them a 'chocolate fireguard' is just a bit strong. I'm sure that they are doing the best they can within the organisation that they were given to work with. In fact, I know they are.
As I've posted, my own opinion is that the format adopted by the MAA for reports makes it harder for them to be clearly understood and acted upon. In this case, the technical factors were reasonably clear, but the organisational aspects were less clearly established. And that brings up to the issue of how far up the chain the SI can go in looking at the 'organisational' stuff. I agree with Tuc that the SI should have found out why the aircraft's Safety Case was so badly compromised. It should also have established why the airworthiness trail for the RTI (which is supposed to be auditable) was so thin.
But I don't think that any SI is going to be able to go back tens of years and look at funding and policy decisions by VSOs that contributed to the present situation. My own view is that the MoD has to be responsible, at all levels, for managing and preserving 'Air Safety', which includes airworthiness. That means people have to do their job. The basics haven't changed. What does bother me is that a number of managers within the system no longer have a clear idea of what 'the basics' involve.
Best Regards as ever to all those working the issues,
Engines
Engines, I take your gentle differing in the spirit with which it is offered and certainly take the point that the personnel of the MilAAIB did as good a job as they could in the circumstances. It is those circumstances with which I take issue.
If the AAIB were a part of the CAA and there were airworthiness related accidents occurring one after the other in the civil air fleets because of systemic failures that rendered airworthiness provision dysfunctional under the CAA (the civil airworthiness authority), then the AAIB would be placed in the impossible position of finding Gross Negligence in its parent organisation. It wouldn't of course, because it is independent of the CAA for that very reason.
Here we have the whole incestuous relationship of UK Military Airworthiness Provision and Air Accident Investigation laid bare. The formation of the MAA has if anything worsened the situation that preceded Haddon Cave. There at least was the possibility that a well informed BoI President, prepared to go out on a limb in defiance of his superiors might just start asking the questions that I have suggested. The remote possibility of such a loose cannon has now been resolved by nesting the MilAAIB within the MAA, the very organisation that has inherited the Mare's Nest that is UK Military Airworthiness Provision. The VSO's can rest easy!
It is all very well for SI's to say, "not my job, mate!" when I suggest that they should delve deeper, but if they don't then they are part of the same problem that is the MAA, the Nimrod Report, and the MOD, ie the great cover up of the deliberate destruction of UK Military Airworthiness Provision. That is why 63 people died in the various airworthiness related air accident threads in the PPRuNe Military Forum. You'd think that would concern Air Accident Investigators, wouldn't you?
If the AAIB were a part of the CAA and there were airworthiness related accidents occurring one after the other in the civil air fleets because of systemic failures that rendered airworthiness provision dysfunctional under the CAA (the civil airworthiness authority), then the AAIB would be placed in the impossible position of finding Gross Negligence in its parent organisation. It wouldn't of course, because it is independent of the CAA for that very reason.
Here we have the whole incestuous relationship of UK Military Airworthiness Provision and Air Accident Investigation laid bare. The formation of the MAA has if anything worsened the situation that preceded Haddon Cave. There at least was the possibility that a well informed BoI President, prepared to go out on a limb in defiance of his superiors might just start asking the questions that I have suggested. The remote possibility of such a loose cannon has now been resolved by nesting the MilAAIB within the MAA, the very organisation that has inherited the Mare's Nest that is UK Military Airworthiness Provision. The VSO's can rest easy!
It is all very well for SI's to say, "not my job, mate!" when I suggest that they should delve deeper, but if they don't then they are part of the same problem that is the MAA, the Nimrod Report, and the MOD, ie the great cover up of the deliberate destruction of UK Military Airworthiness Provision. That is why 63 people died in the various airworthiness related air accident threads in the PPRuNe Military Forum. You'd think that would concern Air Accident Investigators, wouldn't you?
But I don't think that any SI is going to be able to go back tens of years and look at funding and policy decisions by VSOs that contributed to the present situation. My own view is that the MoD has to be responsible, at all levels, for managing and preserving 'Air Safety', which includes airworthiness. That means people have to do their job. The basics haven't changed. What does bother me is that a number of managers within the system no longer have a clear idea of what 'the basics' involve.
I entirely agree with this, not least because, with the passage of time, it is very unlikely that an SI panel will have the individual or collective experience or knowledge to ask the question. In my experience, your typical BoI or SI engineering member has never served in a post that would expose him to the detail of airworthiness assurance; and that is where the Devil lies. And aircrew would simply not be expected to know, in the same way I would never expect to be asked about piloty stuff.
This is where MAA oversight comes in. They most definitely DO know of these problems from tens of years ago; because they remain current, they have been told this in the form of formal reports, submissions to Haddon-Cave and Lord Philip and during meetings with Ministers. Yet, they (MAA) are willing party to recent DE&S and Ministerial rulings, upholding the rulings of Alcock's crowd 21 years ago (Baker, December 1992), that refusing to make "savings at the expense of safety" is an offence. (What is it about Bakers? It was another Baker who upheld the same ruling in MoD(PE) on 9.9.02, a ruling still cited by DE&S, Ministers and the Head of the Civil Service and provided under FoI).
Please consider that fact. Then ask why the MAA was established. Because Haddon-Cave condemned this long standing policy of "savings at the expense of safety". (Only he conveniently omitted to say it was policy since 1988). That is, the MAA and DE&S are on record as disagreeing with the very premise upon which the MAA was formed. You couldn't make it up.
Most in MAA would, I hope, be astonished at what is being said in their name. But the fact remains, and is fully documented, that their senior staffs are fully aware of these continuing systemic failings, routinely condone them and flatly refuse to officially recognise them. That refusal and gross dereliction of duty can be seen in what is omitted from the RAFAT SI report. Perhaps, in private, they are fuming. But demonstrably they vent their spleen on those, like me, who tell the truth, while actively protecting those responsible for so many deaths. Do us all a favour and resign now.
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Some posters accepted and praised this SI as thorough and entirely credible when it was first published. The real airworthiness experts on this forum have subsequently highlighted serious and indefensible shortcomings in the conduct and conclusions of this SI and in the way the MAA, who are responsible for it, continues to carry out its business. The very thorough and scientific investigation into the seat aspects by 1710 NAS is one of the few positive elements of what is, in my opinion, a sloppy, misleading and incomplete piece of work.
On a more human level, please do not overlook the SI's deliberate targeting of the RAFAT's culture and ethos in their report. Based loosely on psychometric theory, stereotype preconceptions, unsubstantiated assertions presented as fact and some dubious interpretation of training records, most of which have subsequently been challenged and disproved, the integrity and professionalism of the pilots was publicly questioned and declared a contributory factor in this tragic accident. This unprofessional, disgraceful and indefensible personal blame game must have caused considerable anguish and anger within the team, who were themselves victims in the tragedy.
As an outsider but with some knowledge of the true facts of this case, I find the MAA's endorsement of this aspect of the SI absolutely outrageous.
On a more human level, please do not overlook the SI's deliberate targeting of the RAFAT's culture and ethos in their report. Based loosely on psychometric theory, stereotype preconceptions, unsubstantiated assertions presented as fact and some dubious interpretation of training records, most of which have subsequently been challenged and disproved, the integrity and professionalism of the pilots was publicly questioned and declared a contributory factor in this tragic accident. This unprofessional, disgraceful and indefensible personal blame game must have caused considerable anguish and anger within the team, who were themselves victims in the tragedy.
As an outsider but with some knowledge of the true facts of this case, I find the MAA's endorsement of this aspect of the SI absolutely outrageous.
Last edited by Genstabler; 28th Feb 2014 at 11:07.
Tecumseh and Engines
I was being specific in that the technical investigation was part of the SI,not the complete SI per se.
I know it is a subtle point,and I do realise the wider responsibility of airworthiness,I was merely (again) praising the technical side of the investigation.
I was being specific in that the technical investigation was part of the SI,not the complete SI per se.
I know it is a subtle point,and I do realise the wider responsibility of airworthiness,I was merely (again) praising the technical side of the investigation.
LR
Thank you and yes, I agree. What was published was technically sound. Like others, I wonder what wasn't published!
My view comes from regarding airworthiness as an engineering discipline and thus expecting a section in every such report that makes a positive statement that they have assessed the currency and validity of, at least, the Aircraft Document Set. Few SIs, or BOIs before them do this. This one went further than most, stating that the Safety Case report doesn't exist. Then, nothing, despite the next logical step being the Whole Aircraft Safety Case. I simply cannot believe any engineer would fail to dig deeper. Especially, post-Haddon-Cave.
I wonder at the restrictive boundaries they have to work to. It is crystal clear to me that the MAA audits of 2010/11-ish have highlighted the long standing policy and practice of regarding Safety as a complete waste of money. How can the SI/MAA/MoD meet its obligation to try to prevent recurrence if it doesn't address such an obvious root cause?
That is why I suspect the MAA have omitted much, allowing attention to be diverted to the other allegations mentioned by Genstabler. Whoever has failed in this Duty diminishes themselves by their refusal to acknowledge the truth. We desperately need a BoI/SI President or Coroner with the balls to recommend a reconvening on the grounds they have been lied to, or misled by omission or commission.
Thank you and yes, I agree. What was published was technically sound. Like others, I wonder what wasn't published!
My view comes from regarding airworthiness as an engineering discipline and thus expecting a section in every such report that makes a positive statement that they have assessed the currency and validity of, at least, the Aircraft Document Set. Few SIs, or BOIs before them do this. This one went further than most, stating that the Safety Case report doesn't exist. Then, nothing, despite the next logical step being the Whole Aircraft Safety Case. I simply cannot believe any engineer would fail to dig deeper. Especially, post-Haddon-Cave.
I wonder at the restrictive boundaries they have to work to. It is crystal clear to me that the MAA audits of 2010/11-ish have highlighted the long standing policy and practice of regarding Safety as a complete waste of money. How can the SI/MAA/MoD meet its obligation to try to prevent recurrence if it doesn't address such an obvious root cause?
That is why I suspect the MAA have omitted much, allowing attention to be diverted to the other allegations mentioned by Genstabler. Whoever has failed in this Duty diminishes themselves by their refusal to acknowledge the truth. We desperately need a BoI/SI President or Coroner with the balls to recommend a reconvening on the grounds they have been lied to, or misled by omission or commission.
Engines and Tecumseh.
Sorry I had written a longer post but decided to delete most of it (esp cos I was at work at the time ; ) !) .
As another forumite posted earlier...any investigation will pick up procedural shortcomings in almost any organisation ....so perhaps to a certain extent - there but for the grace of big G go all of us.
rgds LR
Sorry I had written a longer post but decided to delete most of it (esp cos I was at work at the time ; ) !) .
As another forumite posted earlier...any investigation will pick up procedural shortcomings in almost any organisation ....so perhaps to a certain extent - there but for the grace of big G go all of us.
rgds LR
I'm interested in something you said earlier tuc. The RTI didn't meet the criteria for an RTI. That's been said before on other accidents. A Servicing Instruction on the Mull of Kintyre Chinook that shouldn't have been. A Service Mod on the ASaCs that broke every rule. Same on the Tornado shot down by the US. Bad that none of the SI or BOI mentioned these. 
dervish
Correct. And each directly related to a casual factor noted by the BoI, yet they missed the fact the implementation broke the regulations. The detail I mentioned earlier. And in each case the Safety Case was not updated when the SI(T) or SEM was issued, which breached ..........
If you've never done it, you'd never notice. But it was spotted and included in evidence to Lord Philip, seen by the MAA. Yet, the same happens again on Hawk.
Edited to add that my comment obviously applies less so to the Chinook, because the fact the aircraft was not permitted to fly was withheld from the BoI by Bagnall and Spiers, so they totally ignored airworthiness issues!!
Correct. And each directly related to a casual factor noted by the BoI, yet they missed the fact the implementation broke the regulations. The detail I mentioned earlier. And in each case the Safety Case was not updated when the SI(T) or SEM was issued, which breached ..........
If you've never done it, you'd never notice. But it was spotted and included in evidence to Lord Philip, seen by the MAA. Yet, the same happens again on Hawk.
Edited to add that my comment obviously applies less so to the Chinook, because the fact the aircraft was not permitted to fly was withheld from the BoI by Bagnall and Spiers, so they totally ignored airworthiness issues!!
Last edited by tucumseh; 28th Feb 2014 at 18:18.
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What I find strange is that Martin Baker SIL 407 was issued just a few days after the accident, but it does not get mentioned in the SI report. And yet, testing was carried out using the criteria set out in the document (para 1.4.3.9) which suggested that the new approach was OK. Yes, I know there are those who will say that SIL 407 came after the accident, but this was the immediate mitigation in order to prevent other accidents. In the same way Nimrod fuel loads were reduced after the XV230 accident. That fact got mentioned by the BOI and the Coroner.
However, we now know that the "new approach" was not OK; hence the introduction of the feeler gauge in SIL 407A two years later. This too fails to get a metion at the Inquest.
It does appear to me that every effort has been made to steer the "cause", and blame away from seat failure to inadvertent pulling of the firing handle.
DV
However, we now know that the "new approach" was not OK; hence the introduction of the feeler gauge in SIL 407A two years later. This too fails to get a metion at the Inquest.
It does appear to me that every effort has been made to steer the "cause", and blame away from seat failure to inadvertent pulling of the firing handle.
DV
Returning to the absence of a safety case for the seat it is worth re-reading this BoI (another tragic loss of a top bloke) in a fresh light:
https://www.gov.uk/government/upload...ornado_rpt.pdf
https://www.gov.uk/government/upload...ornado_rpt.pdf
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Seat Modification
I note that a modification was introduced to the MK10 ejection seat in Tornado aircraft which replaced the scissor shackle with a gas shackle. Does anyone know what advantages the later has over the former?
DV
DV
The mod as a whole was advertised as improving low altitude performance, although it also included a new parachute and a gas bladder to push the parachute pack out of the headbox more quickly. I couldn't say what the advantage of the gas shackle in isolation is supposed to be. What I do know is that the shackle link and the offending bolt are still present, and can be "wiggled" if desired to check that the link hasn't been clamped onto the shackle.
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What I do know is that the shackle link and the offending bolt are still present, and can be "wiggled" if desired to check that the link hasn't been clamped onto the shackle.
DV