Flt. Lt. Sean Cunningham inquest
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Much has clearly been learned from the investigation into this tragedy, and there are some findings of systemic failings. I don't share your desire to to try to find people to punish. (Or scapegoats.)
I agree. Human beings make mistakes. What happened, why did it happen, what can we do to prevent it happening again. Open honest reporting to break that chain.
I have flown the Mk10 in 2 RAF types and I remain stunned that I knew so little of the potential risks and that my own training and my own checks were ineffective. I did however completely understand that the signing for events not actually completed was a serious service offence.
Human beings make mistakes. What happened, why did it happen, what can we do to prevent it happening again. Open honest reporting to break that chain.
I wholeheartedly agree with your comments as applied to the vast majority, but there is a malign controlling influence at the heart of all these accidents, and they are continually allowed to judge their own case.
We should never lose sight of the fact MoD will always try to compartmentalise and localise the issue. The simple fact is, we've been here before and, yet again, the systemic failures have their roots in the same policies.
Neither should we lose sight of the fact the SI looks at the cause of the incident (the inadvertent firing); the subsequent death is an unfortunate outcome. The Coroner, on the other hand, looks at the cause of death - which focuses on chute failure. MoD's focus, the firing, conveniently directs attention away from the long term systemic failings and the DIRECT links to previous accidents. The SI does a good job, and points to this, but is not allowed to dwell or even offer an explanation for these failings. There are many recommendations, but no explanation as to why they are necessary. Much to MoD's relief, I imagine.
I'd also like to say that, while I'm critical of the MAA hierarchy, who today are part of this "controlling influence", these failures are so long term (1980s) and deeply embedded in MoD policy and practice, that it would be nigh on impossible to eradicate them in the 4 years the MAA has existed. In that four years, we have seen the instigators of the policies even write to the press defending themselves, and their exact words repeated in the House by the Secretary of State. Being MAA DG under that weight is a crap job. But at no point did either MAA DG write to the SofS and say "You're being lied to". Which is why it would be better off outwith MoD. As you say,
Open honest reporting to break that chain
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For me, one of the key things that is needed is to extend the concept of Just Culture into the organisational context. Whilst there have been (some) improvements in the implementation of Just Culture to those at the pointy end of things, the process stops at those directly involved in the occurrence itself. If Just Culture, and all the other elements of culture that goes with it, was extended throughout the organisations involved in the causal factors hopefully the individuals making the decisions will feel more protected when they do things that are justified and with the best of intentions. Likewise, should anyone choose to do something less honourable, they would be aware that they were crossing a defined "line in the sand" for which they would be held accountable.
The challenge of course, would be for the MAA as the Regulator to enforce such a process and audit its application.
The challenge of course, would be for the MAA as the Regulator to enforce such a process and audit its application.
FL, I really cannot be so dismissive of the pilots' 'paperwork'.
The deliberate falsification of continuation training, instrument flying and instrument approach records is a wholly different matter to mere forgetfulness.
It's the difference between forgetting to submit your income tax return (Jack Swigert, Apollo 13) and making a false declaration.
In PPL terms, it's the difference between forgetting to get your Class Rating revalidation signed by the due date and deliberately 'Parker penning' the necessary hours to revalidate by experience.....
If, as seems likely from the SI, there was a culture amongst RAFAT to consider such lying and cheating normal, then that to my mind indicates a cavalier attitude towards operations in general. Which is reinforced by the wholly pointless abbreviated 'timeline' from brief to take-off and the non-adherance to mandatory Hawk FRC procedures.
The deliberate falsification of continuation training, instrument flying and instrument approach records is a wholly different matter to mere forgetfulness.
It's the difference between forgetting to submit your income tax return (Jack Swigert, Apollo 13) and making a false declaration.
In PPL terms, it's the difference between forgetting to get your Class Rating revalidation signed by the due date and deliberately 'Parker penning' the necessary hours to revalidate by experience.....
If, as seems likely from the SI, there was a culture amongst RAFAT to consider such lying and cheating normal, then that to my mind indicates a cavalier attitude towards operations in general. Which is reinforced by the wholly pointless abbreviated 'timeline' from brief to take-off and the non-adherance to mandatory Hawk FRC procedures.
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The deliberate falsification of continuation training, instrument flying and instrument approach records is a wholly different matter to mere forgetfulness.
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Beagle, I fear that you are up against a brick wall there.
There is a sense of the "justice" that we see in RTA offence prosecution there. I admit it is a difficult balance, but take this example.
Speeding, in a defective car, loss of control and car collides with a wall. No injury but extensive damage to property.
Same scenario, but two pedestrians between car and wall, one dead & one maimed and in need of extensive support and care for the remainder of their days.
The actions of the driver are the same in each case, but will be dealt with differently by the court.
All's well that ends well seems to pervade the GA community with regards to documentation, and now we see evidence of it in the Reds as well.
How on earth can the Reds have continued to operate in this fashion after another SI pointed out the same failings a few years before?
Tucumseh is forever bangining on about VSO conspiracy to cover up unlawful instructions which have cost lives, and we all need people like him to speak up. I had thought, and hoped, that such practices were not happening at squadron level, but it seems to be so.
There is a sense of the "justice" that we see in RTA offence prosecution there. I admit it is a difficult balance, but take this example.
Speeding, in a defective car, loss of control and car collides with a wall. No injury but extensive damage to property.
Same scenario, but two pedestrians between car and wall, one dead & one maimed and in need of extensive support and care for the remainder of their days.
The actions of the driver are the same in each case, but will be dealt with differently by the court.
All's well that ends well seems to pervade the GA community with regards to documentation, and now we see evidence of it in the Reds as well.
How on earth can the Reds have continued to operate in this fashion after another SI pointed out the same failings a few years before?
Tucumseh is forever bangining on about VSO conspiracy to cover up unlawful instructions which have cost lives, and we all need people like him to speak up. I had thought, and hoped, that such practices were not happening at squadron level, but it seems to be so.
Obviously it is regrettable that military airworthiness provision continues to fall short of the standards that once prevailed, and I hope that some of the evidence presented plus the convening cuthority's comments help tuc et al continue to move their campaign forward. However, as tuc observed, the report does not make airworthiness failings its focus; rather than see this as obfuscation, I see it as a reflection of where the truly shocking failures in this accident occurred.
Now that the report is out I'll be more blunt than in my earlier comments. Airworthiness provision cannot alone deliver safe flying operations. The operating outfit has a responsibility to provide a certain level of personnel competence and appropriate procedures because even the most airworthy equipment will fail if abused. In this case, technical shortcomings went unidentified; how, exactly, was DE&S supposed to identify them until one or the other was laid bare?. That almost falls into the 'bad stuff happens' category for me, so the truly shocking aspect is the degree to which lax supervision and shoddy operating practices demolished the defences which aircrew and techies normally rely on to cope with occasional emergence of 'bad stuff'. All the "ops stuff" as an earlier poster put it is totally relevant - progressive erosion of safety margins created the holes through which this and three other recent avoidable RAFAT accidents could occur (I include the Cranwell gear-up landing).
In hindsight it's evident that the unit culture was rotten - witness the recent 'Reds to wed' business if any further dirty laundry from the preceding OC's tenure is required. If heads are to roll, they're to do with shocking supervision of a squadron that should have been under tight scrutiny given the history of display flying, elite units, three crashes and a fatality (too many coincidences here by far, I'm afraid). It sounds as if the AOC's interest in the programme was based solely on the risk of over-flying the hours (2-star PowerPoint management, anyone?) and beyond that it was "business as usual" in the club. Appalling.
Now that the report is out I'll be more blunt than in my earlier comments. Airworthiness provision cannot alone deliver safe flying operations. The operating outfit has a responsibility to provide a certain level of personnel competence and appropriate procedures because even the most airworthy equipment will fail if abused. In this case, technical shortcomings went unidentified; how, exactly, was DE&S supposed to identify them until one or the other was laid bare?. That almost falls into the 'bad stuff happens' category for me, so the truly shocking aspect is the degree to which lax supervision and shoddy operating practices demolished the defences which aircrew and techies normally rely on to cope with occasional emergence of 'bad stuff'. All the "ops stuff" as an earlier poster put it is totally relevant - progressive erosion of safety margins created the holes through which this and three other recent avoidable RAFAT accidents could occur (I include the Cranwell gear-up landing).
In hindsight it's evident that the unit culture was rotten - witness the recent 'Reds to wed' business if any further dirty laundry from the preceding OC's tenure is required. If heads are to roll, they're to do with shocking supervision of a squadron that should have been under tight scrutiny given the history of display flying, elite units, three crashes and a fatality (too many coincidences here by far, I'm afraid). It sounds as if the AOC's interest in the programme was based solely on the risk of over-flying the hours (2-star PowerPoint management, anyone?) and beyond that it was "business as usual" in the club. Appalling.
Last edited by Easy Street; 7th Feb 2014 at 08:38.
Easy Street:-
...and nobody here has suggested that it can, AFAIK, but we have seen the tragic results of the lack of it in thread after thread in this forum.
From the moment that seat was placed in that aircraft there existed a potential for an airworthiness related accident to happen and sure enough it did, with fatal consequences.
Now we have the curious situation that a report into that accident has been issued by the UK Military Airworthiness Authority, aka the MAA, aka the MOD, and you say that:-
How very unsurprising!
Self Regulation Doesn't Work and in Aviation it Kills!
Airworthiness provision cannot alone deliver safe flying operations.
From the moment that seat was placed in that aircraft there existed a potential for an airworthiness related accident to happen and sure enough it did, with fatal consequences.
Now we have the curious situation that a report into that accident has been issued by the UK Military Airworthiness Authority, aka the MAA, aka the MOD, and you say that:-
the report does not make airworthiness failings its focus
Self Regulation Doesn't Work and in Aviation it Kills!
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I am pleased that the covening authority recognised the professionalism of the panel in the inquiry process.
I wish to highlight that the conduct of this Inquiry has not only been challenging from a technical perspective, but also emotionally so for the panel members................their duties have necessarily brought them into direct contact with a proud and at times, perhaps understandably, defensive organisation..........The panel have conducted themselves wholly professionally and have striven for objectivity - I acknowledge their moral courage in doing so and thank them for it.
I'm 100% with Chug and tuc on this.
Way back in 1988 the RAF Engineering Branch dined out ACM Sir Bill Richardson at RAF Abingdon. He was the last true Chief Engineer - CE(RAF) - and he was held in total admiration and respect by the whole Branch, as was evident by the mass turn out on the evening. On his watch Sir Bill had presided over a system that was fit for purpose.
Since then we have seen the insidious and continual erosion of the airworthiness chain, overseen by a succession of inadequate, unaccountable and unfocused VSOs (even the title CE disappeared) who now remain in self-supporting denial despite a series of well-publicised, airworthiness-related accidents.
It is relatively easy to bring to book an operator who has sharp pencilled flying stats. However, it is is much more difficult (and unpalatable to some) to call to account the actions of the VSOs whose actions have reduced the UK military airworthiness system to the sorry state that it is today.
So, Chug and tuc, continue with your campaign and I wish you success!
Way back in 1988 the RAF Engineering Branch dined out ACM Sir Bill Richardson at RAF Abingdon. He was the last true Chief Engineer - CE(RAF) - and he was held in total admiration and respect by the whole Branch, as was evident by the mass turn out on the evening. On his watch Sir Bill had presided over a system that was fit for purpose.
Since then we have seen the insidious and continual erosion of the airworthiness chain, overseen by a succession of inadequate, unaccountable and unfocused VSOs (even the title CE disappeared) who now remain in self-supporting denial despite a series of well-publicised, airworthiness-related accidents.
It is relatively easy to bring to book an operator who has sharp pencilled flying stats. However, it is is much more difficult (and unpalatable to some) to call to account the actions of the VSOs whose actions have reduced the UK military airworthiness system to the sorry state that it is today.
So, Chug and tuc, continue with your campaign and I wish you success!
Chug - I don't think we'll have to wait too long for an SI report that will be a real acid test of the MAA's integrity and will provide plenty for the airworthiness campaign to get its teeth into (I speak of course of Tornado CWS). But I really feel that the flaws in the Mk10 seat design could not reasonably have been anticipated or spotted by MoD / DE&S - which is all the more evident since the seat was in service in halcyon pre-cuts days. No system is ever 100% safe or foolproof, which is why operators need training, experience and procedures to mitigate known and, to the extent practicable, unknown weaknesses in their kit. Two technical weaknesses snuck through the system at no obvious fault of DE&S, and erosion of the accepted operator safeguards allowed them to line up. Desperately unlucky, and far more attributable to the breakneck pace at which cockpit activity was conducted than any VSO meddling with airworthiness funding long after the Mk10 was in service.
I fully support your campaign and look forward to you taking MoD apart over Tornado CWS!
I fully support your campaign and look forward to you taking MoD apart over Tornado CWS!
One other thing - it's the Military Aviation Authority so it can focus on whatever aspect of an accident it feels appropriate, not just airworthiness!
Easy Street
While I agree with the vast majority of what you say, I think you are too kind to DE&S. After all, they are just a rebrigaded DPA and DLO, and MoD(PE)/AMSO before, with the same people (or their acolytes) in charge.
The SI report has many recommendations pointing to abject failures on DE&S's part (and their predecessors). It doesn't spell them out or explain the background, but that is the way of SIs. But ANY civilian engineer in DE&S with more than 5 years service should know;
That is a top level system failure and any investigation should uncover this fact very quickly, especially as it was a major factor in Nimrod, Chinook, Sea King, Tornado, Hercules etc etc. It is the recurring nature of this failure that should disturb everyone.
Haddon-Cave rightly reported the failure was implementation. The MAA is concentrating on re-writing the regulations. The SI report is all about failure to implement perfectly good regulations. That indicates a system that is not fit for purpose.
I've deliberately avoided mentioning the aircrew and leaders of the Red Arrows. Many excellent posts above say it all.
While I agree with the vast majority of what you say, I think you are too kind to DE&S. After all, they are just a rebrigaded DPA and DLO, and MoD(PE)/AMSO before, with the same people (or their acolytes) in charge.
The SI report has many recommendations pointing to abject failures on DE&S's part (and their predecessors). It doesn't spell them out or explain the background, but that is the way of SIs. But ANY civilian engineer in DE&S with more than 5 years service should know;
a. Backwards, the procedural Defence Standard that, if implemented, would have prevented these failures, and that,
b. It was canceled without replacement about 5 years ago.
Every MoD Technical Agency was issued with his/her own copy of both books, for permanent retention. Still got mine. It is THE bible. If you take the engineering recommendations of the SI, I can point you to the section in the Def Stan that covers it, and is mandated. b. It was canceled without replacement about 5 years ago.
That is a top level system failure and any investigation should uncover this fact very quickly, especially as it was a major factor in Nimrod, Chinook, Sea King, Tornado, Hercules etc etc. It is the recurring nature of this failure that should disturb everyone.
Haddon-Cave rightly reported the failure was implementation. The MAA is concentrating on re-writing the regulations. The SI report is all about failure to implement perfectly good regulations. That indicates a system that is not fit for purpose.
I've deliberately avoided mentioning the aircrew and leaders of the Red Arrows. Many excellent posts above say it all.
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Bronx (#406)
I am afraid that AVM Jerry Connelly is 100% spot on. The airworthiness failures have been flagged up for action in numerous reports; Chinook, Nimrod, Hercules and H-C. They have all been ignored. This line of thinking is ignored by the SI Board and Coroner, probably because noone has been allowed to draw their attention to the evidence.
DV
I am afraid that AVM Jerry Connelly is 100% spot on. The airworthiness failures have been flagged up for action in numerous reports; Chinook, Nimrod, Hercules and H-C. They have all been ignored. This line of thinking is ignored by the SI Board and Coroner, probably because noone has been allowed to draw their attention to the evidence.
DV
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Thinks......
Is it possible to permanently install a small mirror to the aft face of the control column, such that the seat occupant would be able to view the correct installation of the pin, moving the column as required to optimise the viewing angle?
Obviously, consideration of full & free movement of the control column is the priority here.
HB
Obviously, consideration of full & free movement of the control column is the priority here.
HB
HB, although I understand your suggestion, it would be a far from simple matter to modify the control column as you suggest. There would also be considerable risk of sunlight reflections causing distraction. When glued to a mate's wing, the last thing you would want would be a sudden flash in your peripheral vision from the lower cockpit area.
I only did 145 hrs on the Hawk 30+ years ago during a Valley refresher and at Chivenor, but I don't recall a single instance of a problem checking that the seat firing handle was correctly stowed and pinned.
I don't believe that there is a significant problem, provided that there is sufficient 'timeline' allowance for the pre-flight checks to be carried out diligently.
I only did 145 hrs on the Hawk 30+ years ago during a Valley refresher and at Chivenor, but I don't recall a single instance of a problem checking that the seat firing handle was correctly stowed and pinned.
I don't believe that there is a significant problem, provided that there is sufficient 'timeline' allowance for the pre-flight checks to be carried out diligently.
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Is a lack of integrity widespread in today's RAF ?
The deliberate falsification of continuation training, instrument flying and instrument approach records is a wholly different matter to mere forgetfulness.
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Words from Warren Buffett come to mind that give a great perspective when looking for new hires which states :
“ In looking for people to hire, you look for three qualities: integrity, intelligence, and energy. And if you don’t have the first, the other two will kill you. You think about it; it’s true. If you hire somebody without integrity, you really want them to be dumb and lazy.” Well said Mr. Buffett! The perception of the integrity of an organization depends on the pattern of actions of management, which are observed by the employees on a day to day basis. These patterns are consistent of management behaviors, personal values, beliefs, and actions that are thought to be acceptable within the organization’s guidelines, values, and principles.
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Flt Lt Cunningham died because of a failure of his seat to do what it was designed to do. The events leading to this tragic event have been investigated in detail and we all have a view in hindsight of how ths event could have been avoided. No doubt "Lessons will be learnt" as always and life carries on.
What has shocked the most is the realisation that lying and cheating was common place among the team and those in command turned a blind eye or possibly encouraged these actions. Personal integrity appeares to have counted for little in this group of aviators.
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Words from Warren Buffett come to mind that give a great perspective when looking for new hires which states :
“ In looking for people to hire, you look for three qualities: integrity, intelligence, and energy. And if you don’t have the first, the other two will kill you. You think about it; it’s true. If you hire somebody without integrity, you really want them to be dumb and lazy.” Well said Mr. Buffett! The perception of the integrity of an organization depends on the pattern of actions of management, which are observed by the employees on a day to day basis. These patterns are consistent of management behaviors, personal values, beliefs, and actions that are thought to be acceptable within the organization’s guidelines, values, and principles.
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Flt Lt Cunningham died because of a failure of his seat to do what it was designed to do. The events leading to this tragic event have been investigated in detail and we all have a view in hindsight of how ths event could have been avoided. No doubt "Lessons will be learnt" as always and life carries on.
What has shocked the most is the realisation that lying and cheating was common place among the team and those in command turned a blind eye or possibly encouraged these actions. Personal integrity appeares to have counted for little in this group of aviators.