Martin Baker to be prosecuted over death of Flt Lt. Sean Cunningham
BigGreenGilbert - tuc is of course right when he points out the safety of the public as one reason for us all having a right to know about the Dark Hawk. I certainly don’t want to find myself wearing a Hawk of any kind when I’m just walking along minding my own business.
But there’s surely a moral reason as well. That Dark Hawk is public property - our taxes paid for it. There are probably only three reasons why we shouldn’t be allowed to know the details - confidentiality involving either personal privacy or commercial sensitivity, and national security. As far as I know, none of those applies here.
Does it not occur to you that your
displays the kind of arrogance that still expects unquestioning deference for superiors (of which perhaps you may be one)? I believe those attitudes should have disappeared years ago.
airsound (who's sorry for the thread drift)
But there’s surely a moral reason as well. That Dark Hawk is public property - our taxes paid for it. There are probably only three reasons why we shouldn’t be allowed to know the details - confidentiality involving either personal privacy or commercial sensitivity, and national security. As far as I know, none of those applies here.
Does it not occur to you that your
what makes you think you have any righ to know about it?
airsound (who's sorry for the thread drift)
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That there would be a dangerous precedent, because the minute you start to ignore the written instructions / manuals, the whole lot for the aircraft might as well be slung in the bin... just because it tells you in the written instructions that you can lift off in 1000 metres with a maximum of XYZ fuel onboard, do you double that fuel load and ignore the book on a 1000 metre runway?
JTO the phrase same but different applies. IIRC the Typhoon Flight Jacket (LSJ/LP) uses Kevlar reinforced Arm Restraint Extension Lines attached to the jacket sleeves (these plug into the seat QRB - QRF in old money), unlike Tornado, where the arm restraint lugs are attached to the jacket arm and the restraint lines were part of the seat (?).
I'd like to say that what happened to you friend wouldn't happen today, from experience the kit is tested to the nth degree via high speed wind-blast testing, live ejections, 'wet drills', burn tests, etc.
I'd like to say that what happened to you friend wouldn't happen today, from experience the kit is tested to the nth degree via high speed wind-blast testing, live ejections, 'wet drills', burn tests, etc.
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Flight Idle,
Again that can be a dodgy course, say you think it is overtightened and XYZ chief tells you ignore the book and XYZ is wrong, you are carrying the can for your actions in not following the laid down procedures. I know, it seems wrong, but thats how it is, also look at the other thing, if the aircraft is needed how long does it take to pass this up the chain and assuming it does not get stopped on route, to get a reply from the manufacturer and a response back down that chain.
Civi Wise I can contact my Manufacturers rep who will contact the Company design team and I can have an answer emailed to me in a couple of days.
Though sadly the CAA of late have allowed parts of the maintainence manuals to be ignored, that in my eyes is a disaster waiting to happen, as a piecemeal approach leaves what to do and what to ignore up to the individual as opposed to you having to follow it all.
Again that can be a dodgy course, say you think it is overtightened and XYZ chief tells you ignore the book and XYZ is wrong, you are carrying the can for your actions in not following the laid down procedures. I know, it seems wrong, but thats how it is, also look at the other thing, if the aircraft is needed how long does it take to pass this up the chain and assuming it does not get stopped on route, to get a reply from the manufacturer and a response back down that chain.
Civi Wise I can contact my Manufacturers rep who will contact the Company design team and I can have an answer emailed to me in a couple of days.
Though sadly the CAA of late have allowed parts of the maintainence manuals to be ignored, that in my eyes is a disaster waiting to happen, as a piecemeal approach leaves what to do and what to ignore up to the individual as opposed to you having to follow it all.
I can have an answer emailed to me in a couple of days.
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Easy to say.
As nutty and others have alluded to, the problems are still with us even now and nothing is being done to ensure issues like these are PREVENTED in the first place.
First port of call?
Skill of hand. Followed by an enquiring mind.
Basic, basic stuff.
Is it too much to ask?
As nutty and others have alluded to, the problems are still with us even now and nothing is being done to ensure issues like these are PREVENTED in the first place.
First port of call?
Skill of hand. Followed by an enquiring mind.
Basic, basic stuff.
Is it too much to ask?
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Here is the threat. Childish as my views may seem to Bob, this is not about my right to know, it's about everyone's right to have everyone know. Telling the world why that Hawk went dark is not a threat to national security, however it might well be a threat to commercial opportunities for the people at Warton.
Despite the clear rules, people eventually do things in a different manner, and for a while it's all good. Then someone dies, and in the aftermath, we learn (again) the lessons of years ago.
We all know about the foam in the C130 fuel tanks, so there is little or no chance of a C130 going into a combat zone without that and nobody being aware.
The situation with the Hawk T2 however.... Imagine the scene in 15 years from now, and three contractors later, nobody still on the flight line at Valley from last summer.
Because it has been kept quiet, nobody talks about it, so it never gets passed down the line, and the same bad practice creeps in, for the same reason that it crept in last time.
A solo student is caught out, this time at night, and he (understandably) collides with an airliner.
Who are the MoD going to blame that on?
Back to the thread topic.....
I might have misunderstood, but I thought that, and I'm happy to be corrected here, MB have declared that the seat failed because the RAFAT mechanics failed to service the seat properly,
yet the report said the last work on the seat was carried out at Valley on 24th October.
On the basis that I'm right there, am I also right to say the RAFAT mechanics are in blue suits (literally) and the Valley people are civilian contractors? I'm genuinely asking, I've not been to Scampton, or Valley, for years.
As for the SI report, I found the bit at 1.4.5.23a & b quite interesting.
Section 1.4.5.24 directly contradicts Gilbert's assertion that good practice always evolves.
The term used is "incorrectly authorized deviation" when discussing the fact that the Reds had rules, that were not compliant with what had been agreed and written down, by the people responsible for agreeing and writing down the rules.
Why is it so hard for the RAF to find **** like that before someone dies? What on earth is going through the heads of people making changes to procedures, and not getting approval? How can anyone give approval without having checked the impact of the changes.
As for.......
"The positive picture of flight safety and the state of publications and pilot log books appears to be contrary to the findings in this Section.
It is the Panel's view that the Formal Staff Visit may not have provided the AOC with an accurate picture of the RAFAT upon which to base his report."
Sometimes you need to say it very clearly. Either the RAFAT suddenly went off the rails, big time, just after the AOC's inspection, or there wasn't much real inspecting getting done.
Despite the clear rules, people eventually do things in a different manner, and for a while it's all good. Then someone dies, and in the aftermath, we learn (again) the lessons of years ago.
We all know about the foam in the C130 fuel tanks, so there is little or no chance of a C130 going into a combat zone without that and nobody being aware.
The situation with the Hawk T2 however.... Imagine the scene in 15 years from now, and three contractors later, nobody still on the flight line at Valley from last summer.
Because it has been kept quiet, nobody talks about it, so it never gets passed down the line, and the same bad practice creeps in, for the same reason that it crept in last time.
A solo student is caught out, this time at night, and he (understandably) collides with an airliner.
Who are the MoD going to blame that on?
Back to the thread topic.....
I might have misunderstood, but I thought that, and I'm happy to be corrected here, MB have declared that the seat failed because the RAFAT mechanics failed to service the seat properly,
In a statement issued by the firm after entering the guilty plea, it said: "It should be noted that this was an isolated failure relating to the tightening of a nut during maintenance procedures conducted by RAF Aerobatic Team mechanics."
On the basis that I'm right there, am I also right to say the RAFAT mechanics are in blue suits (literally) and the Valley people are civilian contractors? I'm genuinely asking, I've not been to Scampton, or Valley, for years.
As for the SI report, I found the bit at 1.4.5.23a & b quite interesting.
Section 1.4.5.24 directly contradicts Gilbert's assertion that good practice always evolves.
The term used is "incorrectly authorized deviation" when discussing the fact that the Reds had rules, that were not compliant with what had been agreed and written down, by the people responsible for agreeing and writing down the rules.
Why is it so hard for the RAF to find **** like that before someone dies? What on earth is going through the heads of people making changes to procedures, and not getting approval? How can anyone give approval without having checked the impact of the changes.
As for.......
"The positive picture of flight safety and the state of publications and pilot log books appears to be contrary to the findings in this Section.
It is the Panel's view that the Formal Staff Visit may not have provided the AOC with an accurate picture of the RAFAT upon which to base his report."
Sometimes you need to say it very clearly. Either the RAFAT suddenly went off the rails, big time, just after the AOC's inspection, or there wasn't much real inspecting getting done.
I’m astonished at M-B’s guilty plea. Even assuming the company couldn’t prove that it had informed MoD of the risk of over-tightening in 1990 (along with all the other users), its lawyers must surely have been aware of the 2002 QinetiQ report? The latter date rings true to me for another reason: undergoing a course on a Mk10-equipped aircraft around that time, I distinctly remember the ground school instructor advising us to give the drogue shackle link a ‘wiggle’ to check it wasn’t pinched. Unless this had always been part of Mk10 groundschool patter (can’t remember that far back!) then intra-MoD awareness of the 2002 report would explain why the potential fault was highlighted.
Easy Street
Well said.
The HSE charges were 'catch all', and specifics were not revealed until very late in the day; probably why M-B pleaded not guilty last year. It emerged in October that the two charges related to (a) quality of design, and (b) failure to send out a technical bulletin in 1990. The legal strategy dreamed up by their solicitors was 'don't upset MoD'. The quality of product charge, for obvious reasons, was the one to concentrate on.
The company statement (posted by airsound the other day) implies the quality of product charge was dropped. Those in court confirm this, although the way it was presented was apparently vague. If true, and even if guilty, the paperwork one would be a minor administrative error. (The allegation relates to 1990, but even the SI report admits the information was known by the correct people in 1991). The problem the company created for themselves was that media and public opinion was already tainted by the Coroner's inaccuracies and ill-informed comment - caused in part by MoD concealing relevant evidence, including the 2002 report. M-B and their solicitors have a copy obviously, but the strategy meant it wasn't used. I think this poor, because it would have cleared them of both charges.
(Remember, the SI report was not published until after the Inquest, and the MAA issued a written statement five days after evidence had finished that the family had only just been given a copy. Nobody could possibly prepare a case in time against MoD's version).
This report is actually a catch-up exercise by QQ, as MoD required independent safety assurance for Mk10A seat mods that had been developed and trialled in 1998, as a result of the 1996 Tornado Airworthiness Review Team report (TART). The mods were approved in 1999, but lacked an audit trail. One mod negated the risk of over-tightening the nut. This report closed the loop. The TART report is also what clears M-B on the paperwork, the Director of Flight Safety repeating his 1992 criticism that dissemination of safety information by the RAF was poor. (MoD denied the existence of TART for many years; and in this Hawk case MoD claimed no knowledge whatsoever of when the mods were developed or why. This lie was repeated in the House. You always follow the lie).
All this was too late for M-B, and it is plain the senior Director made an executive decision to plead, and get it over with. This was made very recently, because even a few days before the court appearance former MoD employees were standing by to give evidence, having been sought out by the solicitors (not come forward themselves).
Hope this helps. It will be interesting to hear what's said in court next month, if reported. Regardless, the truth will be published!
Well said.
The HSE charges were 'catch all', and specifics were not revealed until very late in the day; probably why M-B pleaded not guilty last year. It emerged in October that the two charges related to (a) quality of design, and (b) failure to send out a technical bulletin in 1990. The legal strategy dreamed up by their solicitors was 'don't upset MoD'. The quality of product charge, for obvious reasons, was the one to concentrate on.
The company statement (posted by airsound the other day) implies the quality of product charge was dropped. Those in court confirm this, although the way it was presented was apparently vague. If true, and even if guilty, the paperwork one would be a minor administrative error. (The allegation relates to 1990, but even the SI report admits the information was known by the correct people in 1991). The problem the company created for themselves was that media and public opinion was already tainted by the Coroner's inaccuracies and ill-informed comment - caused in part by MoD concealing relevant evidence, including the 2002 report. M-B and their solicitors have a copy obviously, but the strategy meant it wasn't used. I think this poor, because it would have cleared them of both charges.
(Remember, the SI report was not published until after the Inquest, and the MAA issued a written statement five days after evidence had finished that the family had only just been given a copy. Nobody could possibly prepare a case in time against MoD's version).
This report is actually a catch-up exercise by QQ, as MoD required independent safety assurance for Mk10A seat mods that had been developed and trialled in 1998, as a result of the 1996 Tornado Airworthiness Review Team report (TART). The mods were approved in 1999, but lacked an audit trail. One mod negated the risk of over-tightening the nut. This report closed the loop. The TART report is also what clears M-B on the paperwork, the Director of Flight Safety repeating his 1992 criticism that dissemination of safety information by the RAF was poor. (MoD denied the existence of TART for many years; and in this Hawk case MoD claimed no knowledge whatsoever of when the mods were developed or why. This lie was repeated in the House. You always follow the lie).
All this was too late for M-B, and it is plain the senior Director made an executive decision to plead, and get it over with. This was made very recently, because even a few days before the court appearance former MoD employees were standing by to give evidence, having been sought out by the solicitors (not come forward themselves).
Hope this helps. It will be interesting to hear what's said in court next month, if reported. Regardless, the truth will be published!
tuc, thank you for the insightful reply.
‘Don’t upset MoD’ seems to me a disastrously misguided strategy. What would MoD do if upset? Buy American or Russian? Mount a disinformation campaign to scupper M-B’s overseas sales? With the idea of a UK industrial strategy being in fashion that’s politically unthinkable. It’s probably legally impossible too. On the other hand, the damage inflicted on the company’s reputation by the guilty plea is very real. Unless I’m missing something crucial this is a woeful misjudgment by M-B.
‘Don’t upset MoD’ seems to me a disastrously misguided strategy. What would MoD do if upset? Buy American or Russian? Mount a disinformation campaign to scupper M-B’s overseas sales? With the idea of a UK industrial strategy being in fashion that’s politically unthinkable. It’s probably legally impossible too. On the other hand, the damage inflicted on the company’s reputation by the guilty plea is very real. Unless I’m missing something crucial this is a woeful misjudgment by M-B.
Last edited by Easy Street; 25th Jan 2018 at 22:48.
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I’m astonished at M-B’s guilty plea. Even assuming the company couldn’t prove that it had informed MoD of the risk of over-tightening in 1990 (along with all the other users), its lawyers must surely have been aware of the 2002 QinetiQ report? The latter date rings true to me for another reason: undergoing a course on a Mk10-equipped aircraft around that time, I distinctly remember the ground school instructor advising us to give the drogue shackle link a ‘wiggle’ to check it wasn’t pinched. Unless this had always been part of Mk10 groundschool patter (can’t remember that far back!) then intra-MoD awareness of the 2002 report would explain why the potential fault was highlighted.
As regards the product design quality charge, I suspect that it may have been dropped because of a difficulty in determining, after many years in service, how much of the design could truly be assigned to MBA's responsibility. I can think of many instances of designers' preferences for in-service fixes being 'discouraged' by PTs etc. Warnings, procedures, instructions, training etc. being cheaper are often preferred over proper modifications. In the safety world they have a desirability order of priority for fixing safety problems and 'elimination' of the hazard always comes first in the order.
BTW this isn't to say that PTs don't need to have a strong influence on matters. Unfortunately the HASAWA contains separate duties for designers/manufacturers and operators and this wasn't well recognised in MAA regs. Industry did make representations on this to the MAA on several aspects of the regs but from memory (warning: may be faulty these days) the only outcome was some words in Def Stan 00-56 to the effect that compliance with the Def Stan does not necessarily mean that parties' legal duties are satisfied. This lack of clarity was a driver for a certain engine company issuing so-called 'duty of care' letters to try and mitigate their own liability situation. Unfortunately, many believe that such letters can actually make it worse.
EAP
EAP86
Excellent observations. Had the case proceeded on the quality of product charge, and if M-B had chosen to defend themselves, there would have been much commonality in the defence to both charges. One being that the seat was serviced to an illegal / rogue Routine Technical Instruction, devised and issued by MoD and in breach of every know regulation. The fact is, by its own admission MoD was well aware of the information it claims M-B did not provide, and did not incorporate it in the RTI or, it seems, training.
Excellent observations. Had the case proceeded on the quality of product charge, and if M-B had chosen to defend themselves, there would have been much commonality in the defence to both charges. One being that the seat was serviced to an illegal / rogue Routine Technical Instruction, devised and issued by MoD and in breach of every know regulation. The fact is, by its own admission MoD was well aware of the information it claims M-B did not provide, and did not incorporate it in the RTI or, it seems, training.
I think (IMHO, sadly) MB have taken a pragmatic commercial decision to take the hit and get on with life. However, I am saddened that MoD has not taken responsibility for obvious failings on their part and fessed up. It is obvious that responsibility has to be taken for this unnecessary death, but it would appear that more blame attaches to MOD than MB, whose excellent product has saved very many lives.
Although the HSE cannot prosecute the MoD, even in the event of a fatal accident, it is very surprising to me that they have not censured them, which they are at liberty to do. I agree with many of the posters in this thread, it seems much more of the liability for this tragic accident lies with MoD, rather than Martin Baker.
From a vendor aspect, the situation with regard to service bulletins on Hawk equipment could be confusing. Every export Hawk instruction would normally go through BAe Systems to the customer. However since the UK MoD dealt directly with Martin Baker on all aspects of the T Mk 1 seat design and mod standard, BAe Systems would not try to read across the export instructions to the T Mk 1 and advise MoD as they would assume MoD had been sent an equivalent instruction directly from Martin Baker. Whether Martin Baker did that and it went missing in MoD I have no idea.
I have to confess I cannot remember seeing the equivalent export service bulletin but someone in Flight Systems or Airworthiness at Brough could probably find a copy with my signature on the covering form.
Walbut
From a vendor aspect, the situation with regard to service bulletins on Hawk equipment could be confusing. Every export Hawk instruction would normally go through BAe Systems to the customer. However since the UK MoD dealt directly with Martin Baker on all aspects of the T Mk 1 seat design and mod standard, BAe Systems would not try to read across the export instructions to the T Mk 1 and advise MoD as they would assume MoD had been sent an equivalent instruction directly from Martin Baker. Whether Martin Baker did that and it went missing in MoD I have no idea.
I have to confess I cannot remember seeing the equivalent export service bulletin but someone in Flight Systems or Airworthiness at Brough could probably find a copy with my signature on the covering form.
Walbut
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Martin Baker seats
Does anyone know what the current situation is regarding the type of shackle fitted to the Red Arrow Mk10 B ejection seats. Is it gas or scissor?
DV
DV
The RAF Hawk TMk1 fleet still have the original standard Mk10 seats with the scissor shackle. The broadly similar seats in the Tornado fleet were modified a few years ago to incorporate the gas shackle. The Hawk TMk2 fleet have the newer lightweight seats with the gas shackle.
CAEBr
CAEBr
Sentencing on 23rd Feb
For those who missed it - Lincoln Crown Court, 12 and 13th Feb.
A bit of to and fro during the two days pre-sentencing hearing. Speeches for the prosecution and defence as reported by the Beeb 12th -
Red Arrows death: Ejection seat firm 'put lives at risk' - BBC News
and 13th - Red Arrows death: Ejection seat failure a 'once every 115 years' event - BBC News
and rather more luridly in the Daily Express.
M-B has already agreed to pay £550,000 prosecution costs.
Adjourned to 23 February for sentencing.
..................
A bit of to and fro during the two days pre-sentencing hearing. Speeches for the prosecution and defence as reported by the Beeb 12th -
Red Arrows death: Ejection seat firm 'put lives at risk' - BBC News
and 13th - Red Arrows death: Ejection seat failure a 'once every 115 years' event - BBC News
and rather more luridly in the Daily Express.
M-B has already agreed to pay £550,000 prosecution costs.
Adjourned to 23 February for sentencing.
..................
Last edited by Lordflasheart; 15th Feb 2018 at 22:31.
It appears the 'quality of design' charge wasn't dropped, per se, but HSE conceded (for some extraordinary reason) that CAD wasn't available to Martin-Baker in 1947. Better to say HSE agreed the level of severity was lower than at first implied.
This doesn't detract from the fact that the offending design, and the resultant risk of the Scissor Shackle/Drogue Shackle jamming due to nut over-tightening, was designed out in 1990, but MoD declined to adopt the modification in Hawk. The 1 in 115 years calculation was not adjusted when poor training and engineering practices developed. In any case, the existence of a minor mod that eliminated the risk altogether, meant MoD bore a risk in Hawk that was not ALARP.
I understand the judge expressed uncertainty as to what to do. Hence, the 10 days to think. She was less than pleased at M-B's last minute change of plea. A few days previously, having been informed of evidence concealed by MoD, she had the sense to call it forward. But she didn't ask why HSE had proceeded in the face of this evidence, which raised considerable doubt over the safety of the prosecution. Perhaps she's just got to accept they pleaded.
It will be interesting to see what she does. I keep thinking of this...
1. 56 of the SI's 60 recommendations were mandated policy.
2. All 17 contributory factors were MoD liabilities.
3. Of the 3 aggravating factors, 2 were MoD liabilities, and one shared with M-B.
4. Of the 6 other factors, 5 were MoD liabilities, and one shared with M-B.
5. All 13 observations were MoD liabilities.
This doesn't detract from the fact that the offending design, and the resultant risk of the Scissor Shackle/Drogue Shackle jamming due to nut over-tightening, was designed out in 1990, but MoD declined to adopt the modification in Hawk. The 1 in 115 years calculation was not adjusted when poor training and engineering practices developed. In any case, the existence of a minor mod that eliminated the risk altogether, meant MoD bore a risk in Hawk that was not ALARP.
I understand the judge expressed uncertainty as to what to do. Hence, the 10 days to think. She was less than pleased at M-B's last minute change of plea. A few days previously, having been informed of evidence concealed by MoD, she had the sense to call it forward. But she didn't ask why HSE had proceeded in the face of this evidence, which raised considerable doubt over the safety of the prosecution. Perhaps she's just got to accept they pleaded.
It will be interesting to see what she does. I keep thinking of this...
1. 56 of the SI's 60 recommendations were mandated policy.
2. All 17 contributory factors were MoD liabilities.
3. Of the 3 aggravating factors, 2 were MoD liabilities, and one shared with M-B.
4. Of the 6 other factors, 5 were MoD liabilities, and one shared with M-B.
5. All 13 observations were MoD liabilities.
Interesting indeed, tuc.
IMHO, I hope that judgemental common sense will prevail and the sentence when it comes will be 'ALARP' in it's own right.
MBA do not deserve this.
IMHO, I hope that judgemental common sense will prevail and the sentence when it comes will be 'ALARP' in it's own right.
MBA do not deserve this.