Fatal Accident Inquiries and Inquest
BGG:-
Hear, hear! The battle for investigation and regulation reform has been waged on many threads on this forum and in many and various ways beyond, but we still have a system of self regulation and accident investigation that is mainly unchanged other than the freshly painted signs outside offices. There is no single answer to getting this rogue super tanker to change course, but every effort to do so is well worth it. These threads are not posted as mere information or even entertainment sources, they are a call to arms for all concerned aviation professionals.
I'm not sure how any self proclaimed professionals could claim not to be concerned, but there are invariably new readers to this forum who may be unaware of the many airworthiness related UK Fatal Military Air Accident threads herein. Rather than condemn them to dedicating the next two or three years to reading through them all, I would point them instead to the latest book by David Hill, "Breaking the Military Covenant - Who speaks for the dead?". Details can be obtained via pm to tucumseh but it covers, inter alia, the loss of two Sea-Kings mid-air, Tornado/Patriot shootdown, Nimrod XV230, Hercules XV179, and the Reds' Hawk inadvertent ground ejection. These and others account for over 100 needless and avoidable deaths. With this one book you can appreciate the woods rather than be preoccupied with the far too many trees, and thus avoid the MOD's default trap of stove-piping accidents as all one-offs. They are not, they are all connected by a dysfunctional and broken system, as David Hill reveals.
Crack on Distant Voice! All it needs is for good men to do something instead of nothing.
DV has looked long and hard at this and he clearly thinks there is merit in pursuing this line. In my own humble opinion, he should be supported. There are some pretty glaring gaps in both the justice system and the way such accidents are investigated.
I'm not sure how any self proclaimed professionals could claim not to be concerned, but there are invariably new readers to this forum who may be unaware of the many airworthiness related UK Fatal Military Air Accident threads herein. Rather than condemn them to dedicating the next two or three years to reading through them all, I would point them instead to the latest book by David Hill, "Breaking the Military Covenant - Who speaks for the dead?". Details can be obtained via pm to tucumseh but it covers, inter alia, the loss of two Sea-Kings mid-air, Tornado/Patriot shootdown, Nimrod XV230, Hercules XV179, and the Reds' Hawk inadvertent ground ejection. These and others account for over 100 needless and avoidable deaths. With this one book you can appreciate the woods rather than be preoccupied with the far too many trees, and thus avoid the MOD's default trap of stove-piping accidents as all one-offs. They are not, they are all connected by a dysfunctional and broken system, as David Hill reveals.
Crack on Distant Voice! All it needs is for good men to do something instead of nothing.
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Double Standards by the Scottish Crown Office
Tornado (MAA, in-house inquiry lasting 15 months carried out by serving officers not trained in accident investigation).
In a statement, the Crown Office said: "After thorough consideration of the circumstances of the case, Crown Counsel have concluded that all the relevant issues have been comprehensively examined in the course of the Military Aviation Authority report and could not have been better considered in any FAI."
Clutha (AAIB, independent inquiry lasting two years carried out by internationally recognised specialist in accident investigation)
In a statement, the Crown Office said, “this [FAI] will be held as soon as is possible. An FAI will allow a full public airing of all the evidence at which families and other interested parties will be represented. It is right that the evidence can be vigorously tested in a public setting and be the subject of judicial determination”.
Can everyone spot the difference?
DV
In a statement, the Crown Office said: "After thorough consideration of the circumstances of the case, Crown Counsel have concluded that all the relevant issues have been comprehensively examined in the course of the Military Aviation Authority report and could not have been better considered in any FAI."
Clutha (AAIB, independent inquiry lasting two years carried out by internationally recognised specialist in accident investigation)
In a statement, the Crown Office said, “this [FAI] will be held as soon as is possible. An FAI will allow a full public airing of all the evidence at which families and other interested parties will be represented. It is right that the evidence can be vigorously tested in a public setting and be the subject of judicial determination”.
Can everyone spot the difference?
DV
Well the serving officers do train as accident investigators and complete the very same course as their AAIB colleagues. They also share the same building, facilities, tea bar and occasionally the milk. The AAIB routinely support their military colleagues and the reciprocal is also true.
I think you are mistaking them with the board members who are deliberately taken from areas of relevant expertise and, typically, the board president is drawn from a different service too. They are also the fresh set of eyes but they do not try their hand at kicking over metal at an accident site and having their best guess - that is left to the professionally trained and experienced individuals drawn from the military and civilian side of the AAIB.
Please note that the Clutha accident suffered significant third-partly casualties and took place in a built-up area, so the legal public interest test is different.
I think you are mistaking them with the board members who are deliberately taken from areas of relevant expertise and, typically, the board president is drawn from a different service too. They are also the fresh set of eyes but they do not try their hand at kicking over metal at an accident site and having their best guess - that is left to the professionally trained and experienced individuals drawn from the military and civilian side of the AAIB.
Please note that the Clutha accident suffered significant third-partly casualties and took place in a built-up area, so the legal public interest test is different.
DV. Spot on.
MAA and AAIB investigators/panel members have very different roles. Even if trained in the same way, the MAA people do not have to apply that training in the same way.
The 2011 Red Arrows case showed up once and for all how lacking MoD investigations are. In a way their errors and mistakes were excusable, as none would have been trained in the necessary disciplines. But they didn't ask those who were. Otherwise, how could they miss that the ejection seat was not permitted in the aircraft? A first year apprentice would be crucified if he couldn't see that.
MoD and HSE then lied. The only question is whether the latter lied under oath.
MAA and AAIB investigators/panel members have very different roles. Even if trained in the same way, the MAA people do not have to apply that training in the same way.
The 2011 Red Arrows case showed up once and for all how lacking MoD investigations are. In a way their errors and mistakes were excusable, as none would have been trained in the necessary disciplines. But they didn't ask those who were. Otherwise, how could they miss that the ejection seat was not permitted in the aircraft? A first year apprentice would be crucified if he couldn't see that.
MoD and HSE then lied. The only question is whether the latter lied under oath.
DV:-
The difference that I see is that one may have confidence in the civil process, whereas that conducted by the MAA is dysfunctional because the UK Military Airworthiness process is dysfunctional and will remain so until UK Military Air Regulation and Investigation is entirely separated from the MOD and each other.
How many UK Military Fatal Air accident threads have to be posted here for that to be recognised and acted upon? How many lives must be needlessly lost and money wasted until that be recognised and acted upon? How many RAF VSO reputations must be protected before that is recognised and acted upon?
This scandal worsens with every death, with every lost air fleet, with every JO, SO, and Company reputation rubbished to protect these men. It is corrupting the Armed Forces and our ability to defend ourselves from those who would do us harm. Enough already!
Can everyone spot the difference?
How many UK Military Fatal Air accident threads have to be posted here for that to be recognised and acted upon? How many lives must be needlessly lost and money wasted until that be recognised and acted upon? How many RAF VSO reputations must be protected before that is recognised and acted upon?
This scandal worsens with every death, with every lost air fleet, with every JO, SO, and Company reputation rubbished to protect these men. It is corrupting the Armed Forces and our ability to defend ourselves from those who would do us harm. Enough already!
Of course they have to apply that training in the same way, otherwise it would be impossible for the civilian and military investigators to work together. If there was any nefarious actions on the military side you would have an in-place panel of experts on the civilian side that would be star witnesses in any court.
The RN Board President and the MAA went through the Red Arrows with a rake and exposed many issues and apparent wrongdoings within the team over the years. A few officers sat around for quite some time awaiting prosecution decisions. I don't think any of them thought they were subject to a soft process. The DE&S response was far less robust - this is the thread you need to pull on.
The RN Board President and the MAA went through the Red Arrows with a rake and exposed many issues and apparent wrongdoings within the team over the years. A few officers sat around for quite some time awaiting prosecution decisions. I don't think any of them thought they were subject to a soft process. The DE&S response was far less robust - this is the thread you need to pull on.
JTO
I was hoping someone would say the Panel and MilAAIB identified the serial violations, but they were withheld from the final report. Is that what you're saying? Parts of the report are indeed thorough and excellent, but my first year apprentice would have pointed out what's missing, which is always the bit to look for. Repair/maintenance/servicing is not complete until verified. The death of Sean Cunningham in one line, taught in your first week. The remainder of the report should have developed that, exposing the root causes.
It did not mention that the MAA was seriously conflicted, as it was directly involved in this root cause. The regulation requiring the Panel to go straight to PUS was not followed. It is unclear if the Panel recognised the violation, in which case it wouldn't have understood the implications and conflict. But, as I said, they didn't ask. And nothing in their individual background or training would prepare them for it. (Not a criticism, just a simple fact). They did criticise aspects of the violation (development of the RTI) but missed both that it was prohibited and the work it required bypassed the laid down servicing instructions, rendering the seat unsafe and unserviceable. They also missed the rather important fact that the information Martin-Baker were later accused of not providing had been provided, but an instruction issued to groundcrew not to use it. Reiterated two years after the accident. Given this conflict, was it proper for the MAA to provide the prosecution's 'star witness'? (HSE's words, to the BBC).
I agree there were failings in DE&S. Particularly, not having a valid Safety Case, and no Safety Case Report, for the seat and major components of it. (Not just the Hawk variant - Tornado also). But if I were DE&S, I'd point to the greater offence of being instructed in the past not to bother with them, and funding and manpower being pulled to make sure. And false declarations being made by the Air Staff they did exist. (Again, untrained, and poorly advised). The Service Inquiry just stopped at there being no Safety Case Report. Good spot, but how did the projects teams pass MAA audit? Another conflict. Also, the aforesaid star witness declared lack of Safety Cases was irrelevant to airworthiness. DE&S staff must be thoroughly confused, as were the courts.
Which of course doesn't get away from the fact M-B pleaded guilty to not providing information; information which the Judge quoted in her remarks, even naming the MoD official who signed the report. (Did the SI try to track him down? They didn't speak to other witnesses. Or Google and download the information it said couldn't be found).
These issues, and that described by Distant Voice, may seem separate cases. In fact, they share the same root causes and are recurring. One need only read the Nimrod and MoK Reviews.
I was hoping someone would say the Panel and MilAAIB identified the serial violations, but they were withheld from the final report. Is that what you're saying? Parts of the report are indeed thorough and excellent, but my first year apprentice would have pointed out what's missing, which is always the bit to look for. Repair/maintenance/servicing is not complete until verified. The death of Sean Cunningham in one line, taught in your first week. The remainder of the report should have developed that, exposing the root causes.
It did not mention that the MAA was seriously conflicted, as it was directly involved in this root cause. The regulation requiring the Panel to go straight to PUS was not followed. It is unclear if the Panel recognised the violation, in which case it wouldn't have understood the implications and conflict. But, as I said, they didn't ask. And nothing in their individual background or training would prepare them for it. (Not a criticism, just a simple fact). They did criticise aspects of the violation (development of the RTI) but missed both that it was prohibited and the work it required bypassed the laid down servicing instructions, rendering the seat unsafe and unserviceable. They also missed the rather important fact that the information Martin-Baker were later accused of not providing had been provided, but an instruction issued to groundcrew not to use it. Reiterated two years after the accident. Given this conflict, was it proper for the MAA to provide the prosecution's 'star witness'? (HSE's words, to the BBC).
I agree there were failings in DE&S. Particularly, not having a valid Safety Case, and no Safety Case Report, for the seat and major components of it. (Not just the Hawk variant - Tornado also). But if I were DE&S, I'd point to the greater offence of being instructed in the past not to bother with them, and funding and manpower being pulled to make sure. And false declarations being made by the Air Staff they did exist. (Again, untrained, and poorly advised). The Service Inquiry just stopped at there being no Safety Case Report. Good spot, but how did the projects teams pass MAA audit? Another conflict. Also, the aforesaid star witness declared lack of Safety Cases was irrelevant to airworthiness. DE&S staff must be thoroughly confused, as were the courts.
Which of course doesn't get away from the fact M-B pleaded guilty to not providing information; information which the Judge quoted in her remarks, even naming the MoD official who signed the report. (Did the SI try to track him down? They didn't speak to other witnesses. Or Google and download the information it said couldn't be found).
These issues, and that described by Distant Voice, may seem separate cases. In fact, they share the same root causes and are recurring. One need only read the Nimrod and MoK Reviews.
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Armed Forces: Death:Written question - 194225
QuestionAsked by Martin Docherty-Hughes
(West Dunbartonshire)
Asked on: 21 November 2018
Ministry of Defence
Armed Forces: Death
194225
To ask the Secretary of State for Defence, what procedures were in place prior to the 2016 Fatal Accident Act coming into force to brief military personnel and their families on the lack of a mandatory requirement for a Fatal Accident Inquiry in Scotland for military deaths.
Answer
Answered by: Mr Tobias Ellwood
Answered on: 28 November 2018 It has not been possible to establish what, if anything, military personnel and their families may have been told regarding the differences between the English and Scottish legal systems in the event of a death prior to the introduction of the Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016. We can advise that such information is not included in briefing for military personnel and their families should they have been deployed to Scotland post 2016.
Last edited by Distant Voice; 29th Nov 2018 at 11:22. Reason: Clarification
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In the skies over Coldstream Scotland, on 25th April 2018, a scenario developed that was reminiscent of that which led to the collision of two Tornado aircraft over the Moray Firth in 2012. On this occasion it involved two Hawk T1s and two Typhoons, and the outcome could have been catastrophic, involving deaths in the air and on the ground. The associated AIRPROX report states,
"During the investigation, the board noted that neither aircraft was fitted with a CWS. However, the Typhoon is to be fitted with Enhanced Collision Awareness System (ECAS) and Hawk funding has been approved for a yet to be determined CWS; date for introduction/completion of CWS systems into respective fleets was not available."
So Duty Holders are still playing the very dangerous ALARP (Temporal) game - it's ok to drive your car at night without headlights as long as you plan to fit them at some time in the future. This flawed understanding of safety regulations is the real killer and formed part of a case presented to the Lord Advocate to revisit the need for an Fatal Accident Inquiry into the Tornado. Unfortunately, so far, he has failed to grasp the fact that fitting some Tornado aircraft with TCAS does not deal with the overarching procedural problem. Furthermore, he asserts that this is not a public interest issue - tell the people of Coldstream that.
DV
"During the investigation, the board noted that neither aircraft was fitted with a CWS. However, the Typhoon is to be fitted with Enhanced Collision Awareness System (ECAS) and Hawk funding has been approved for a yet to be determined CWS; date for introduction/completion of CWS systems into respective fleets was not available."
So Duty Holders are still playing the very dangerous ALARP (Temporal) game - it's ok to drive your car at night without headlights as long as you plan to fit them at some time in the future. This flawed understanding of safety regulations is the real killer and formed part of a case presented to the Lord Advocate to revisit the need for an Fatal Accident Inquiry into the Tornado. Unfortunately, so far, he has failed to grasp the fact that fitting some Tornado aircraft with TCAS does not deal with the overarching procedural problem. Furthermore, he asserts that this is not a public interest issue - tell the people of Coldstream that.
DV
So picture the scene in a Tornado crewroom a number of years ago or indeed in a Typhoon crewroom next week. Station Commander breaks the following to the crews:
"OK chaps, we have enough money to run 4 Squadrons of Typhoons if you are happy to look out of the window and hope for the best or we can fit collision warners to 3 squadrons of Typhoons. What shall we do?"
Wonder what the crews would say?
"OK chaps, we have enough money to run 4 Squadrons of Typhoons if you are happy to look out of the window and hope for the best or we can fit collision warners to 3 squadrons of Typhoons. What shall we do?"
Wonder what the crews would say?
"OK chaps, we have enough money to run 4 Squadrons of Typhoons if you are happy to look out of the window and hope for the best or we can fit collision warners to 3 squadrons of Typhoons. What shall we do?"
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Are you crowd-funding?
As tucumseh says, it is the only way that it can be tested in court. Having said that, I have it in writing from the MAA that ALARP (Temporal) does not exist.
DV
I would like to hear the opinion of an air defender as to whether a CAS would actually make their lives safer. The system eventually fitted to GR4 was an off the shelf civil system designed for straight and level, single aircraft. Fitted to a fast jet manoeuvring hard and deliberately flying close to other aircraft in the formation it alarmed a lot. And as we know, learning to ignore such warnings is a bad thing. At least, however, the GR4 did not often deliberately fly intercept courses as AD aircraft do. Could it be that one more voice bitching in your ear might actually reduce safety?
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Hi Timelord - I never felt the need for one - but that doesn’t mean much. I’d certainly not want another voice in the cockpit. Perhaps a system you could disable Fencing In and enable Fencing Out?
FWIW I do believe that affordability is an issue. Money spent on a system - mandatory or discretionary, is money that can’t be spent elsewhere. Not saying it shouldn’t be spent on CWS, merely that if you want CWS something has to give.
FWIW I do believe that affordability is an issue. Money spent on a system - mandatory or discretionary, is money that can’t be spent elsewhere. Not saying it shouldn’t be spent on CWS, merely that if you want CWS something has to give.
I am now somewhat out of touch but am reasonably confident that a CWS system that was effective and could protect aircraft engaging in Air Combat or LL affil WITHOUT producing unacceptable levels of false warnings was still out of reach, despite some considerable sums being spent on the problem.
ASRAMTOO
I don't disagree, although it does represent the real legal world. Those who have to deal with this daily in MoD have a difficult task. They look to very senior officers to engage with politicians to resolve these matters. I'd like to hear their side, and what was said the last time they sat with Minister. If they told him the truth (and I know one was told in 2011, but by a member of the public, with the regulatory authority present) then it is he who should be answering in court. That never happens, so might I suggest the entire air safety system is built on weak foundations if it cannot be implemented - or the regulatory authority supinely accepts that it is not implemented.
I don't disagree, although it does represent the real legal world. Those who have to deal with this daily in MoD have a difficult task. They look to very senior officers to engage with politicians to resolve these matters. I'd like to hear their side, and what was said the last time they sat with Minister. If they told him the truth (and I know one was told in 2011, but by a member of the public, with the regulatory authority present) then it is he who should be answering in court. That never happens, so might I suggest the entire air safety system is built on weak foundations if it cannot be implemented - or the regulatory authority supinely accepts that it is not implemented.
tucumseh
I would certainly agree with you that the military safety system has historically let us down. I think one of the areas where it has struggled ( as do many of us on Pprune) is in determining a senible balance between war and peace, especially when that war is undeclared.
Perhaps one of the reasons for this is simply an absence of balls. I think it would be entirely appropriate for a VSO to say:
"That aircraft is not as safe to fly as it should be and no short term fix is available, unfortunately the crew are taking a higher risk than I would normally accept. However in doing so they are saving many lives on the ground so it will continue to operate."
Conversly if the only reason an aircraft does not have an appropriate level of IFF and a box is available that could fix the problem fairly quickly but we are saving cash then the VSO should perhaps say " Cash up or the boys are off to the bar"
It seems that all too often VSOs are less than upfront because they fear the public consequences of command decisions.
So reviewing the various accidents over the past few years to try and determine the occassions where money invested, or decisions not taken might have saved lives is a good thing. Attempting to reduce risk to the levels of an airline would be a bad thing.
I would certainly agree with you that the military safety system has historically let us down. I think one of the areas where it has struggled ( as do many of us on Pprune) is in determining a senible balance between war and peace, especially when that war is undeclared.
Perhaps one of the reasons for this is simply an absence of balls. I think it would be entirely appropriate for a VSO to say:
"That aircraft is not as safe to fly as it should be and no short term fix is available, unfortunately the crew are taking a higher risk than I would normally accept. However in doing so they are saving many lives on the ground so it will continue to operate."
Conversly if the only reason an aircraft does not have an appropriate level of IFF and a box is available that could fix the problem fairly quickly but we are saving cash then the VSO should perhaps say " Cash up or the boys are off to the bar"
It seems that all too often VSOs are less than upfront because they fear the public consequences of command decisions.
So reviewing the various accidents over the past few years to try and determine the occassions where money invested, or decisions not taken might have saved lives is a good thing. Attempting to reduce risk to the levels of an airline would be a bad thing.