Martin Baker to be prosecuted over death of Flt Lt. Sean Cunningham
050
Agreed, and well said. There is so much evidence to counter MoD's main claim. It may be that other evidence has yet to be revealed. But for MoD to escape prosecution, it will have to be much worse than ACAS falsely declaring in the RTS that there was a valid safety case. Of course, MoD has form here, and has escaped prosecution before. I really do wonder why MB haven't played this, and other cards.
Agreed, and well said. There is so much evidence to counter MoD's main claim. It may be that other evidence has yet to be revealed. But for MoD to escape prosecution, it will have to be much worse than ACAS falsely declaring in the RTS that there was a valid safety case. Of course, MoD has form here, and has escaped prosecution before. I really do wonder why MB haven't played this, and other cards.
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thank you tuc
I guess its a case of 'how much do you want to drop one of your primary customers in the poop?' I hope this sorts itself out in the wash, perhaps the deal has already been reached behind the scenes... a court case for appearances and then business as usual.
I guess its a case of 'how much do you want to drop one of your primary customers in the poop?' I hope this sorts itself out in the wash, perhaps the deal has already been reached behind the scenes... a court case for appearances and then business as usual.
hoss183:-
If that is the case then MB and the MOD would jointly be guilty of conspiring to pervert the course of justice. The MOD of course wouldn't bat an eyelid, but MB needs to consider its actions carefully. Nowhere is "behind the scenes" these days. MOD's attempts to pin a manslaughter rap on two deceased JOs is already a matter of record. In short it has form.
Now another man has died, let right be done, and the real culprit be put up for trial.
perhaps the deal has already been reached behind the scenes... a court case for appearances and then business as usual.
Now another man has died, let right be done, and the real culprit be put up for trial.
An observation, if I may?
Re: 'how much do you want to drop one of your primary customers in the poop?'
For several years, the UK MoD has been at best, a `secondary` customer for MBA. However, I believe the perception that "if its good for the RAF, its good enough for us" still (up to ~5 years ago, anyway) held sway with many of the company's other customers.
...but I get the points Hoss and Chug.
Re: 'how much do you want to drop one of your primary customers in the poop?'
For several years, the UK MoD has been at best, a `secondary` customer for MBA. However, I believe the perception that "if its good for the RAF, its good enough for us" still (up to ~5 years ago, anyway) held sway with many of the company's other customers.
...but I get the points Hoss and Chug.
All the legalities aside, the accident report was chilling and informative at the same time, and an excellent piece of work in my opinion (I write reports for a living).
It makes me wonder how many flight crew have accidentally passed a crotch strap through the ejection seat D ring when strapping in and not noticed it. I have seen flexible "crotch shields" on some aircraft that would have prevented this from happening, I believe the early JAS39 seat required some work in this area. It certainly made me think.
A tragedy all round.
It makes me wonder how many flight crew have accidentally passed a crotch strap through the ejection seat D ring when strapping in and not noticed it. I have seen flexible "crotch shields" on some aircraft that would have prevented this from happening, I believe the early JAS39 seat required some work in this area. It certainly made me think.
A tragedy all round.
I find it extremely difficult to understand why ANY pilot could not be utterly meticulous about checking and strapping into his seat, to have any strap out of place , let alone one through the firing handle and no notice the fact is absurdly bad airmanship.
And I still can't imagine why the pin was being replaced on the roll out with other aircraft in the vicinity, why on earth does, or perhaps did, the RAF allow such sloppy procedures?
Pins should only be installed when , ideally stopped, but only when circumstances allow visual confirmation of correct insertion. Period
When I first started on a JP 1962 my QFI hammered into me that the seat could save my life, but if mishandled could just as easily kill me.
Six months later we both ejected and he is coming to lunch today !
All my RAF life, particularly as a QFI myself, I practiced my QFIs teaching
, what changed ?
And I still can't imagine why the pin was being replaced on the roll out with other aircraft in the vicinity, why on earth does, or perhaps did, the RAF allow such sloppy procedures?
Pins should only be installed when , ideally stopped, but only when circumstances allow visual confirmation of correct insertion. Period
When I first started on a JP 1962 my QFI hammered into me that the seat could save my life, but if mishandled could just as easily kill me.
Six months later we both ejected and he is coming to lunch today !
All my RAF life, particularly as a QFI myself, I practiced my QFIs teaching
, what changed ?
RBA/BY, your point is well made and I too remember both the sense of security and the respect that was drummed into me when under instruction on the JP at the same time as you were. As a trainee trucker first the seat went, leaving only a parachute for the Varsity AFTS, and then even that went at the Hastings OCU (bad for passenger morale apparently).
The change in culture that you instance is what happens when an Air Safety system is deliberately and malevolently attacked. It is wrong to suppose that airworthiness alone was a victim of that attack in the late 80s/early 90s, every aspect of Flight Safety was hit; reporting, collating, rectifying, disseminating. Add to that the truculent view that "Safety is for Wimps" and you arrive at the cavalier practices found in this report.
It took mere months to destroy a system that had taken decades to build. It will take more decades to rebuild, and that has to start with an independent Regulator and Investigator, both of the MOD and of each other, in order to avoid a repeat attack. That is the point of an Investigation after all, to avoid a recurrence!
For too long BoIs/MIs have satisfied themselves with counting the trees when it is the woods that need investigating, and that can only be done by investigators independent of those with something to hide.
The change in culture that you instance is what happens when an Air Safety system is deliberately and malevolently attacked. It is wrong to suppose that airworthiness alone was a victim of that attack in the late 80s/early 90s, every aspect of Flight Safety was hit; reporting, collating, rectifying, disseminating. Add to that the truculent view that "Safety is for Wimps" and you arrive at the cavalier practices found in this report.
It took mere months to destroy a system that had taken decades to build. It will take more decades to rebuild, and that has to start with an independent Regulator and Investigator, both of the MOD and of each other, in order to avoid a repeat attack. That is the point of an Investigation after all, to avoid a recurrence!
For too long BoIs/MIs have satisfied themselves with counting the trees when it is the woods that need investigating, and that can only be done by investigators independent of those with something to hide.
And I still can't imagine why the pin was being replaced on the roll out with other aircraft in the vicinity, why on earth does, or perhaps did, the RAF allow such sloppy procedures?
Pins should only be installed when , ideally stopped, but only when circumstances allow visual confirmation of correct insertion. Period
Pins should only be installed when , ideally stopped, but only when circumstances allow visual confirmation of correct insertion. Period
The existence of position 2 and 3 for the SFH were not known about and neither was the possibility of initiating an ejection with anything other than a vertical pull.
The best knowledge at the time was that if you had inserted the pin then the SFH must have been safe. No visual inspection was required, why would it be? The pin wasn't believed to be capable of going anywhere else. In any event, a visual inspection of the pin when the SFH was in position 2 or 3 from the normal seated position would simply show the pin to be "correct" as looking at it from above wouldn't show the problem.
Last edited by Stuff; 18th Jan 2017 at 11:56.
Retired BA/BY
It's easy to criticise but unless you were in Sean's shoes then it is very hard to say you wouldn't have done the same thing.
We are all taught (and for us QFIs we all teach) to be very careful with pins and respectful of EJ seats. Nothing has changed in that regard.
All I can say is that Sean learned a very hard lesson for the eternal benefit of the rest of us. I check my seat pin far closer now than I did before his accident. As Stuff says, we just weren't fully aware of the problem beforehand.
I'm not overly chuffed when people come on here and say things like "I would never have done that" and "what the hell was he thinking?!".
The quote 'Don't judge a man until you have walked a mile in his shoes' springs to my mind. You may well have been a previous FJ pilot and you may have achieved thousands of hours in them but you weren't a Red Arrows pilot in 2011. If the criticism had come from one of the team then I would listen. To the best of my knowledge, this has never happened.
You may disagree with me and I'm not trying to start a fight but those are my thoughts. As a counter argument how would you feel if I were to come onto a similar forum and bad mouth the actions of a BA pilot after a fatal accident? Sure I'm a pilot but I've never flown a heavy transport aircraft.
BV
It's easy to criticise but unless you were in Sean's shoes then it is very hard to say you wouldn't have done the same thing.
We are all taught (and for us QFIs we all teach) to be very careful with pins and respectful of EJ seats. Nothing has changed in that regard.
All I can say is that Sean learned a very hard lesson for the eternal benefit of the rest of us. I check my seat pin far closer now than I did before his accident. As Stuff says, we just weren't fully aware of the problem beforehand.
I'm not overly chuffed when people come on here and say things like "I would never have done that" and "what the hell was he thinking?!".
The quote 'Don't judge a man until you have walked a mile in his shoes' springs to my mind. You may well have been a previous FJ pilot and you may have achieved thousands of hours in them but you weren't a Red Arrows pilot in 2011. If the criticism had come from one of the team then I would listen. To the best of my knowledge, this has never happened.
You may disagree with me and I'm not trying to start a fight but those are my thoughts. As a counter argument how would you feel if I were to come onto a similar forum and bad mouth the actions of a BA pilot after a fatal accident? Sure I'm a pilot but I've never flown a heavy transport aircraft.
BV
Bob Viking,
Surely the fact that the pilot was a member of the Red Arrows in 2011 raises the bar in terms of standard of care?
We surely don't need to await a pronouncement from someone else in the Red Arrows (as if there is likely to be one) to be able to conclude that the crotch strap through the handle was bad form, and was down to the pilot? I am not trying to deflect the general flow of the debate,or alter where the fingers are pointing, but lets call a spade a spade.
Surely the fact that the pilot was a member of the Red Arrows in 2011 raises the bar in terms of standard of care?
We surely don't need to await a pronouncement from someone else in the Red Arrows (as if there is likely to be one) to be able to conclude that the crotch strap through the handle was bad form, and was down to the pilot? I am not trying to deflect the general flow of the debate,or alter where the fingers are pointing, but lets call a spade a spade.
Falcon900
The question of why an experienced operator incorrectly routed his crotch strap may never be answered, although the SI goes to great lengths to attempt to explain. Sean wasn't the first to do it and I'm sure he won't be the last.
I'm not saying it was correct to do so. Sean knew that as well. I just find it a little specious to state that 'it could never happen to me'. You could say that for every accident that ever occurred. The victim of the accident would probably have said the same. But they'd be wrong.
I think I've made my point but I'm sure there is more to discuss.
BV
The question of why an experienced operator incorrectly routed his crotch strap may never be answered, although the SI goes to great lengths to attempt to explain. Sean wasn't the first to do it and I'm sure he won't be the last.
I'm not saying it was correct to do so. Sean knew that as well. I just find it a little specious to state that 'it could never happen to me'. You could say that for every accident that ever occurred. The victim of the accident would probably have said the same. But they'd be wrong.
I think I've made my point but I'm sure there is more to discuss.
BV
Stuff: No need for a ladder, checking visually that the pin was correctly installed is too utterly basic to ignore. Never heard of double checking a critical item, in this case feel and visual observations ?
And as far as Mr Viking is concerned I HAVE walked in very similar shoes to Sean's. So I am VERY critical of the idea of inserting a seat pan firing handle on the rollout and NEVER saw it done because it was certainly not SOP. I question just why it was necessary to insert the pin before safely stopped and parked on the pan. Perhaps there was/is a reason I just don't get it based on the experience of 12 years of flying ejection seat equipped aircraft. After this accident and the associated publicity its a pretty poor state of affairs if Sean is NOT the last to do this. I am not bad mouthing anyone, just critical of the culture based on real life experience and if you wish to be crtitical of any other incident feel free to do so, BUT make it factual and preferrably based on real knowledge or experience.
Never a Red but there have been times when I was rushed but seat checks were NEVER compromised. Perhaps an ejection very early in my career rammed that home and I hammered that home to all my crew and students ( which included commandants designate of CFS and RAFC when I was a standards QFI) for which I make no apology. It served me well.
I could never, ever, say it could NOT have happened to me but I did my damndest to make sure it did not and that includes the double check I mentioned.
And as far as Mr Viking is concerned I HAVE walked in very similar shoes to Sean's. So I am VERY critical of the idea of inserting a seat pan firing handle on the rollout and NEVER saw it done because it was certainly not SOP. I question just why it was necessary to insert the pin before safely stopped and parked on the pan. Perhaps there was/is a reason I just don't get it based on the experience of 12 years of flying ejection seat equipped aircraft. After this accident and the associated publicity its a pretty poor state of affairs if Sean is NOT the last to do this. I am not bad mouthing anyone, just critical of the culture based on real life experience and if you wish to be crtitical of any other incident feel free to do so, BUT make it factual and preferrably based on real knowledge or experience.
Never a Red but there have been times when I was rushed but seat checks were NEVER compromised. Perhaps an ejection very early in my career rammed that home and I hammered that home to all my crew and students ( which included commandants designate of CFS and RAFC when I was a standards QFI) for which I make no apology. It served me well.
I could never, ever, say it could NOT have happened to me but I did my damndest to make sure it did not and that includes the double check I mentioned.
Last edited by RetiredBA/BY; 18th Jan 2017 at 20:39.
Actually Bob the accident report did address that question. They believed the previous pilot flew the aircraft in the exact same condition, and that he exited the cockpit with the now undone crotch strap lying loose but still routed through the seat handle, Sean didn't pass the strap through the handle, it was already there. On recreating the scenario the examiners noted how easy it was to reach down and grab the strap without being able to see the mis-routing.
No need for ill-feeling over this, it was a tragedy and lessons will be learned. RIP Sean.
No need for ill-feeling over this, it was a tragedy and lessons will be learned. RIP Sean.
This needless and avoidable accident should send out a clarion call to the military aviation community of the importance of a fully functioning Air Safety System and what can happen when there isn't one, as then, and as now.
This seat did not have a Safety Case. If it had then a continuous auditing process would have highlighted the possibility of the drogue shackle nut being overtightened as a result of the improper use of an RTI requiring the nut to be unfastened and refastened on the line every 50 hours. It would also have highlighted reports of the SPH pin being inserted leaving the seat live, and for that matter the ease of misrouting the crotch strap through the SPH, and measures would have been taken to alleviate all of these issues.
There was no Safety Case though, and the aircraft RTS was therefore illegal. There was no overview of this vital safety component by the Regulator, rather all was left to the airmanship of the pilots and the professionalism of the ground engineers. The Regulator should be in the dock in my view, attempting to defend the indefensible. Unless and until it is, then needless and avoidable accidents will simply carry on happening...
This seat did not have a Safety Case. If it had then a continuous auditing process would have highlighted the possibility of the drogue shackle nut being overtightened as a result of the improper use of an RTI requiring the nut to be unfastened and refastened on the line every 50 hours. It would also have highlighted reports of the SPH pin being inserted leaving the seat live, and for that matter the ease of misrouting the crotch strap through the SPH, and measures would have been taken to alleviate all of these issues.
There was no Safety Case though, and the aircraft RTS was therefore illegal. There was no overview of this vital safety component by the Regulator, rather all was left to the airmanship of the pilots and the professionalism of the ground engineers. The Regulator should be in the dock in my view, attempting to defend the indefensible. Unless and until it is, then needless and avoidable accidents will simply carry on happening...
I am obviously a bit old fashioned. Safety Cases came in, possibly in the late 90s, not sure, but I sat on ejection seats for 40 years, not just MB, but also Folland and ACES 2. I recall safety being absolutely drummed in to us in initial training and beyond. Particularly partial pin insertion and crotch strap positioning. I don't recall many or any such cases like this one.
This was an absolute tragedy and I do not blame Sean in any way. Despite all the training, I managed to get airborne on a live Q scramble with the straps completely wrong and the seat live. With some trepidation on the climb out, I made the seat safe, unstrapped and did it properly. Things can screw you up and I was lucky nothing else happened. Will a safety case make you absolutely safe or is it just a legal requirement? I don't know.
What I do know is I am grateful for the security that an ejection seat gave me and was happy to sit on one despite its own inherent dangers.
This was an absolute tragedy and I do not blame Sean in any way. Despite all the training, I managed to get airborne on a live Q scramble with the straps completely wrong and the seat live. With some trepidation on the climb out, I made the seat safe, unstrapped and did it properly. Things can screw you up and I was lucky nothing else happened. Will a safety case make you absolutely safe or is it just a legal requirement? I don't know.
What I do know is I am grateful for the security that an ejection seat gave me and was happy to sit on one despite its own inherent dangers.
Safety Cases came in, possibly in the late 90s
All contractors understand this, and very few in my experience would remotely consider defrauding MoD by falsifying safety reports. (I'd like to say "none", but unfortunately I know of two - both led to multiple deaths and injuries, but no action was taken). The problem, admitted by MoD in the Service Inquiry report, is that this process broke down catastrophically in the case of the Mk10 ejection seat. I'd bet my house Martin Baker has a valid Safety Case. As I'd still have the house, I'd bet it again that MoD has not had Martin Baker under appropriate contract, so the MoD Safety Cases have lapsed or just been ignored - and this is what the SI refers to when it admits there is no Safety Case.
In other words, precisely the same as happened on Nimrod MR2, when MoD didn't bother contracting its upkeep for many years, and when an attempt was eventually made to resurrect it, it employed a safety manager who hadn't a clue, as it had been so long since MoD trained anyone. (And therein lies the reason he, and his RAF officer colleagues, were not prosecuted). Which gets us back to XX177 and why (a) the Crown prosecution Service determined that no case could be brought, and (b) the Health and Safety Executive have decided to pursue Martin Baker but not MoD, despite the latter openly admitting serious offences. Something's going on.
Tuc, many thanks for your comeback, your further explanation and correct dating. However, I am still unsure as to whether a Safety Case really makes things completely safe or is just a legal requirement, giving the opportunity for litigation when it goes wrong. Military aviation is inherently dangerous, thats why I am going grey! I prefer to talk in terms of airworthiness, where I have had some experience, not all good I might add.
Mach2number
I agree. It adds a degree of confidence - a high degree if done properly. The real issue is, as you say, practical implementation. The Safety Case for the seat (in this case) must then be subsumed into the whole aircraft Safety Case for the platform, and what is safe in one application may not be in another. That is why the SI report is so alarming - that the MoD system, post-MAA and Haddon-Cave, permitted the basic Safety Case to be ignored. Put another way, what MoD tends to ignore is the difference between physical and functional safety. It (or rather the manufacturer) will usually check the first, but MoD uses that evidence to sign off both. Martin Baker can say the seat is physically safe, but it cannot say it is functionally safe as it has no control over how it is fitted, maintained or used.
I agree. It adds a degree of confidence - a high degree if done properly. The real issue is, as you say, practical implementation. The Safety Case for the seat (in this case) must then be subsumed into the whole aircraft Safety Case for the platform, and what is safe in one application may not be in another. That is why the SI report is so alarming - that the MoD system, post-MAA and Haddon-Cave, permitted the basic Safety Case to be ignored. Put another way, what MoD tends to ignore is the difference between physical and functional safety. It (or rather the manufacturer) will usually check the first, but MoD uses that evidence to sign off both. Martin Baker can say the seat is physically safe, but it cannot say it is functionally safe as it has no control over how it is fitted, maintained or used.
I know that I have asked this (professionally unqualified) question before.
Is there any possible circumstantial link between the events surrounding the death of Sean Cunningham and that of Steve Beckley, who apparently stepped on the bottom handle of his seat ( pins in )and was ejected to his death on ground impact whilst climbing out of a Harrier at Yeovilton c.1974.?
Is there any possible circumstantial link between the events surrounding the death of Sean Cunningham and that of Steve Beckley, who apparently stepped on the bottom handle of his seat ( pins in )and was ejected to his death on ground impact whilst climbing out of a Harrier at Yeovilton c.1974.?
Yes, the SPH issue is not new. It did occur on a Harrier years ago but I don't recall a fatality linked to it. I do remember that the SPH issue was then highlighted in Air Clues or on a poster.