Martin Baker to be prosecuted over death of Flt Lt. Sean Cunningham
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Pobjoy,
Take a look at the SI report on the standards of servicing that were happening on the RAFAT ejections seats. Key issues found:
1. There was no 'Q' course to qualify RAFAT airmen to work on the Hawk. Babcock personnel did a 5 week course - the RAF declined to use this course.
2. The Hawk TMK1 Support policy Statement said that there was no requirement for pre-employment training for airmen before they worked on the RAFAT. The Support Authority were 'unsure' as to why this was the case.
3. Then gaps were made up by OJT carried out by SNCOs. Many of these had no qualifications as instructors, nor was there an approved syllabus.
4. As a result of the above, RAFAT engineers were maintaining Hawk aircraft without any compliant training.
5. RAFAT armourers had no access to a central training cell. They had to rely on OJT to be trained to work on the ejection seats. A number of the RAFAT armourers had no recent experience of working on ejection seat equipped aircraft. One had had no seat experience in the 6 years since his basic training.
6. The SI found evidence of signatory and supervisory malpractice.
I struggle to find reasonable words to express my thoughts on this lot, without appearing to be a permanently grumpy old retired engineer, I really do. Ejection seats can, will, and have killed, and in the RN they were always treated with severe respect. Armourers working on seats were properly trained, qualified, certified, checked, and and there was any dismantling of seat sub -assemblies required, the whole seat came out and went back to the seat shop. Taking seat shackles apart every 50 hours using as setup like this was just asking for trouble. The SI correctly notes it as a contributory factor.
In sum, I simply don't recognise what the SI report sets out as any form of professionally run fast jet maintenance operation. The tragedy is that NONE of this lot is now going to come out, MB having pled guilty.
This is one area where 'hang the guilty b******s' works for me.
Best regards as ever to those doing the best with what they have,
Engines
Take a look at the SI report on the standards of servicing that were happening on the RAFAT ejections seats. Key issues found:
1. There was no 'Q' course to qualify RAFAT airmen to work on the Hawk. Babcock personnel did a 5 week course - the RAF declined to use this course.
2. The Hawk TMK1 Support policy Statement said that there was no requirement for pre-employment training for airmen before they worked on the RAFAT. The Support Authority were 'unsure' as to why this was the case.
3. Then gaps were made up by OJT carried out by SNCOs. Many of these had no qualifications as instructors, nor was there an approved syllabus.
4. As a result of the above, RAFAT engineers were maintaining Hawk aircraft without any compliant training.
5. RAFAT armourers had no access to a central training cell. They had to rely on OJT to be trained to work on the ejection seats. A number of the RAFAT armourers had no recent experience of working on ejection seat equipped aircraft. One had had no seat experience in the 6 years since his basic training.
6. The SI found evidence of signatory and supervisory malpractice.
I struggle to find reasonable words to express my thoughts on this lot, without appearing to be a permanently grumpy old retired engineer, I really do. Ejection seats can, will, and have killed, and in the RN they were always treated with severe respect. Armourers working on seats were properly trained, qualified, certified, checked, and and there was any dismantling of seat sub -assemblies required, the whole seat came out and went back to the seat shop. Taking seat shackles apart every 50 hours using as setup like this was just asking for trouble. The SI correctly notes it as a contributory factor.
In sum, I simply don't recognise what the SI report sets out as any form of professionally run fast jet maintenance operation. The tragedy is that NONE of this lot is now going to come out, MB having pled guilty.
This is one area where 'hang the guilty b******s' works for me.
Best regards as ever to those doing the best with what they have,
Engines
Thanks Engines, I agree, but having taken the origanal CAA regulations and converted them, removed non miltary relevant parts, or amended to fit in with the new way forward for the MAA, applied the regulations to civilan companies working within the military environment, that they did not follow themselves, or understand what it was all about, made for rather confusing and interesting times.
There are a lot in the MAA who are trying to do things right these days, but they are, as has been pointed out on numerous threads like this, sometimes overridden by the hierarchy. It also did not help when they initially filled posts with people who were not compliant with the requirements for those posts, again that just means things got lost in the noise, including safety issues, which this and other threads have illustrated.
The ASIM system using DASOR's only works when people know what should be reported in the first place, then report it if they are not bothered about career progression, and then have people who can investigate, analyse and ultimately put actions in place to stop it happening again, unfortunately it is stovepiped into individual platforms with not much thought to safety issues that could be applicable to others.
A phrase I heard regularly after Haddon Cave report came out was 'nothing to do with us, that is Nimrod only', and we all know that is not correct.
There are a lot in the MAA who are trying to do things right these days, but they are, as has been pointed out on numerous threads like this, sometimes overridden by the hierarchy. It also did not help when they initially filled posts with people who were not compliant with the requirements for those posts, again that just means things got lost in the noise, including safety issues, which this and other threads have illustrated.
The ASIM system using DASOR's only works when people know what should be reported in the first place, then report it if they are not bothered about career progression, and then have people who can investigate, analyse and ultimately put actions in place to stop it happening again, unfortunately it is stovepiped into individual platforms with not much thought to safety issues that could be applicable to others.
A phrase I heard regularly after Haddon Cave report came out was 'nothing to do with us, that is Nimrod only', and we all know that is not correct.
Engines,
You have made some excellent post and identified a number of very valid points.
Having spent most of my 24 years as an armourer working on Mk.10 seats (6 on Hawk) I just need to clear up one thing.
The removal of the Scissor Shackle Bolt is something a properly trained and authorised tradesman would be very familiar with, it has to be disconnected in order to remove the primary cartridge in the top of the ejection gun, part of the dis-arming process that is carried out on every single seat removal.
In my time on Hawk (at 2 TWU 88-94) we had a training cell that monitored our qualifications, with all training carried out locally on the squadron (there never was a Q course for Hawk only an X-annotation). With that many aircraft and student pilots, we pulled seats that often that it became second nature (I could still remove one now from memory).
Back then, most of the guys on RAFAT were ex-Hawk guys from Valley, Brawdy or Chivenor, so they knew the jet well. I understand for some time now, there have been 1st tourist engineers on RAFAT, probably because there is no 'pool' of experience to draw from other Hawk units, as they have been civilianised. However, they should have had to demonstrate their competence in carrying out seat work, prior to being authorised to carry out that work and have a training record to substantiate that.
I have posted previously on this incident, but have not felt comfortable about this for some time due to comments made by certain individuals.
Certainly, on the squadron that I worked on, we were all aware of ensuring the freedom of movement of the parachute withdrawal shackle in 1988. I can only conclude that the general 'dumbing down' of training over the years and a lack of experience have contributed here.
But bear in mind, are talking about the tradesman that did the job, the NCO who carried out the Vital checks and the SNCO who did the Independent checks all missing this one critical failure of a basic task.
Why? Someone should be desperate to answer that question....
You have made some excellent post and identified a number of very valid points.
Having spent most of my 24 years as an armourer working on Mk.10 seats (6 on Hawk) I just need to clear up one thing.
The removal of the Scissor Shackle Bolt is something a properly trained and authorised tradesman would be very familiar with, it has to be disconnected in order to remove the primary cartridge in the top of the ejection gun, part of the dis-arming process that is carried out on every single seat removal.
In my time on Hawk (at 2 TWU 88-94) we had a training cell that monitored our qualifications, with all training carried out locally on the squadron (there never was a Q course for Hawk only an X-annotation). With that many aircraft and student pilots, we pulled seats that often that it became second nature (I could still remove one now from memory).
Back then, most of the guys on RAFAT were ex-Hawk guys from Valley, Brawdy or Chivenor, so they knew the jet well. I understand for some time now, there have been 1st tourist engineers on RAFAT, probably because there is no 'pool' of experience to draw from other Hawk units, as they have been civilianised. However, they should have had to demonstrate their competence in carrying out seat work, prior to being authorised to carry out that work and have a training record to substantiate that.
I have posted previously on this incident, but have not felt comfortable about this for some time due to comments made by certain individuals.
Certainly, on the squadron that I worked on, we were all aware of ensuring the freedom of movement of the parachute withdrawal shackle in 1988. I can only conclude that the general 'dumbing down' of training over the years and a lack of experience have contributed here.
But bear in mind, are talking about the tradesman that did the job, the NCO who carried out the Vital checks and the SNCO who did the Independent checks all missing this one critical failure of a basic task.
Why? Someone should be desperate to answer that question....
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Careful study of this extract from the BoI Report provides many of the answers.
https://www.gov.uk/government/upload...3_analysis.pdf
https://www.gov.uk/government/upload...3_analysis.pdf
Mortmeister
Excellent post.
I simply note that (a) MoD flatly deny this, and (b) the HSE considered it 'irrelevant' when offered in evidence, and did not think it affected their case against M-B for not reminding MoD of this in 1990. I've never worked on ejection seats, but the individual elements are basic fitting, and without hesitation believe you.
Excellent post.
Certainly, on the squadron that I worked on, we were all aware of ensuring the freedom of movement of the parachute withdrawal shackle in 1988.
Exrigger
This is now applied to aspects that were hitherto mandated. I first saw this in about 1999 when a non-engineer line manager had a pop, saying 'Def Stans are not mandatory'. Well, they are, if called up in the contract. And a small series of them are mandated in every aviation contract. Not hundreds - just 4 or 5; and only one that any project manager should know by heart. It is THE Bible. Had it been followed, this accident would not have happened. Many of the recommendations in the SI report, and those in other reports, amount to - implement this Def Stan. Much of the content of these Standards is now 'should' instead of 'shall'. But I wonder if the MAA have actually rescinded the overarching directive that they are mandated? Very confusing for those who have to implement them.
although it is to be noted that there is a lot of use of the word should,
Tucumseh, with regard Def Stans you are correct, however the RA's in one specific area were amended to remove certain information that caused problems for the contractors, the Def Stan still retained the information and was extant within the contracts, but the RA took precedence despite that.
Certainly, on the squadron that I worked on, we were all aware of ensuring the freedom of movement of the parachute withdrawal shackle in 1988.
Of note, when fitted but not deployed, lateral movement of the drogue shackle was possible, giving no indication of an interference fit until loading was applied
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Tucumseh, with regard Def Stans you are correct, however the RA's in one specific area were amended to remove certain information that caused problems for the contractors, the Def Stan still retained the information and was extant within the contracts, but the RA took precedence despite that.
As an aside on the use of "Organization" within the MAA, this arose because of a minor obsession by one of the first Directors of the MAA. While this usage appears in the OED, it is regarded as archaic. A friend in the MAA once told me that the two main internal issues were the use of the 'z' in such spellings and ensuring that the interests of horse riders were given proper attention when it came to low flying and so on.
EAP
EAP86:
As you say that is the correct order of precedence, however, having been involved in MRP 145 approvals since they were introduced for civilian maintenance contractors, this point was argued that the quoted contracted Def Stans took precedence over the RA's that were amended to remove pertinent information, the argument was lost and the companies have to submit a Alternative Acceptable Means of Compliance to work to the Def Stan and not the RA, attempts to amend the RA to re-align with the Def Stan were unsuccesful.
Quote from MAA-03:
And then one wonders why we keep having these threads on here, when the critical safety sytems are full of mis-understandings and confusion, or are simply not followed.
After a fair few years in industry dealing with such matters, I can advise that the recognised order of precedence is that the Contract terms come first, the contractual technical specification next, followed by the RAs etc.
Quote from MAA-03:
1. Acceptable Means of Compliance (AMC) represents the preferred means by which the MAA expects the intent of the Regulation to be met. AMC contain the permissive verb should, highlighted in bold for visual impact, to indicate that another approach may be acceptable.
Therefore if the regulated entity believes it can better achieve the intent of the Regulation by using an Alternative AMC, it may formally apply to the MAA to have this alternative means approved.
Such approval will only be given where the regulated entity can produce evidence to show to the satisfaction of the MAA why the AAMC is necessary and appropriate in lieu of the AMC, and that the AAMC can achieve the requisite level of Air Safety by compliance with the Regulation. After
MAA approval has been given, the applicant is responsible for ensuring that the activities defined in the AAMC are promulgated, understood, and followed appropriately
Therefore if the regulated entity believes it can better achieve the intent of the Regulation by using an Alternative AMC, it may formally apply to the MAA to have this alternative means approved.
Such approval will only be given where the regulated entity can produce evidence to show to the satisfaction of the MAA why the AAMC is necessary and appropriate in lieu of the AMC, and that the AAMC can achieve the requisite level of Air Safety by compliance with the Regulation. After
MAA approval has been given, the applicant is responsible for ensuring that the activities defined in the AAMC are promulgated, understood, and followed appropriately
Tecumseh and engines, thank you, gentlemen, for your detailed reply.
Having read the SI it still sticks in my craw that M.B. were fined for not protecting the RAF
from itself ( at least that is how it appears to me) as there is a list of 14 contributory factors in that SI.
The one item, of several, which really disturbs me is that there was a practice of inserting the. SFH pin WITHOUT visual reference, hard to believe that such a safety critical item was so (mis) managed.
Another thing which I do not understand, and to which no one has yet given a reasonable answer:
If the pin was removed before engine start it follows that taxi OUT was conducted with a live seat.
Why, then, was the SFH pin replacement not left in place during the taxi IN and carefully replaced, with visual observation and confirmation of correct replacement, on reaching the pan and the engine shut down ?
It’s a long time since I was a QFI, (and my own ejection) but I just cannot begin to understand why such an unsafe practice was allowed, tolerated, let alone became an SOP.
Has that practice been changed following this tragic death ?
Having read the SI it still sticks in my craw that M.B. were fined for not protecting the RAF
from itself ( at least that is how it appears to me) as there is a list of 14 contributory factors in that SI.
The one item, of several, which really disturbs me is that there was a practice of inserting the. SFH pin WITHOUT visual reference, hard to believe that such a safety critical item was so (mis) managed.
Another thing which I do not understand, and to which no one has yet given a reasonable answer:
If the pin was removed before engine start it follows that taxi OUT was conducted with a live seat.
Why, then, was the SFH pin replacement not left in place during the taxi IN and carefully replaced, with visual observation and confirmation of correct replacement, on reaching the pan and the engine shut down ?
It’s a long time since I was a QFI, (and my own ejection) but I just cannot begin to understand why such an unsafe practice was allowed, tolerated, let alone became an SOP.
Has that practice been changed following this tragic death ?
There was a 'Q' course in the early days of the Hawk Mort - I did mine at Hawker Squiddelly Dunsfold june/july 1977 whilst on my way to Brawdy for the introduction of Hawks for the TWU.I do not know how many 'Q' courses were actually carried out - not that many I guess.My docs were annotated (something like) Q-AHK-A as I was a rigger.
Same in 1978 - the shackle rattle was always carried out by the aircrew during pre strap in checks.
Certainly, on the squadron that I worked on, we were all aware of ensuring the freedom of movement of the parachute withdrawal shackle in 1988
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Exrigger:
I feel your pain. I was involved with 'MAOS' when ADRP held it's original 'Ad Hoc Sub-Committee' on the subject, the discussions on the original Def Stan 05-130 with ADRP and EngPol, and the subsequent drafting of the relevant RAs.
It was frustrating, to say the least, to discuss issues in the meetings and achieve a degree of mutual understanding only to find that later discussions within the MAA (or with the senior officer levels) left the text unchanged or changed to something even more unacceptable. There seemed to be a view that industry could agree and accept anything and very few realised the strict legal and commercial constraints under which we operated. To be fair, this view wasn't universally held but over the years I observed many shrugs signifying "...I know, but what can I do?"
The maintenance regs were originally drafted as Def Stans because only industry was expected to work to them. Industry has always been discouraged from contracting to MOD internal regs such as JAP100, JSPs, RAs etc because they can change without any involvement from industry; thats why Def Stans existed. Many of these documents were actually caveated to say they were not to be used for contracting purposes but I'm aware that this rule was often disregarded, possibly less so in the Air domain than Land or Sea.
EAP
I feel your pain. I was involved with 'MAOS' when ADRP held it's original 'Ad Hoc Sub-Committee' on the subject, the discussions on the original Def Stan 05-130 with ADRP and EngPol, and the subsequent drafting of the relevant RAs.
It was frustrating, to say the least, to discuss issues in the meetings and achieve a degree of mutual understanding only to find that later discussions within the MAA (or with the senior officer levels) left the text unchanged or changed to something even more unacceptable. There seemed to be a view that industry could agree and accept anything and very few realised the strict legal and commercial constraints under which we operated. To be fair, this view wasn't universally held but over the years I observed many shrugs signifying "...I know, but what can I do?"
The maintenance regs were originally drafted as Def Stans because only industry was expected to work to them. Industry has always been discouraged from contracting to MOD internal regs such as JAP100, JSPs, RAs etc because they can change without any involvement from industry; thats why Def Stans existed. Many of these documents were actually caveated to say they were not to be used for contracting purposes but I'm aware that this rule was often disregarded, possibly less so in the Air domain than Land or Sea.
EAP
Thanks EAP86, I went to RAF Wyton for the original meetings on what became MAOS, and it was comical listening to what was being put forward and the surprise when industry pointed out that some of their ideas would not work. With regard MAP-01 & 02, JAP 02 & 02 as was, were included in the maintenace contracts as there was RAF personnel as part of the workforce and we had to use military paperwork, F700 etc, on that score civilian companies had issues with that as they were wanting to run things independantly from the military, but with MRP-145 approvals and reality kicked in it was realised that this approach would be impractical.
It was also pointed out that RA AMC's quite often link to the MAP-01, so despite trying to deny the link and ignore the MAP-01, to maintain approval the companies have to comply.
Again, it does make one wonder if all this confusion is partly responsible for having the opposite effect on safety than it is designed to safe guard and improve.
It was also pointed out that RA AMC's quite often link to the MAP-01, so despite trying to deny the link and ignore the MAP-01, to maintain approval the companies have to comply.
Again, it does make one wonder if all this confusion is partly responsible for having the opposite effect on safety than it is designed to safe guard and improve.
I read with interest the BOI analysis. I don't know when the requirement for OJT to be carried out by trained Instructors, or personnel having received sufficient training on instructing was introduced. Certainly it was not practice in the 1960s, when I both received and carried out OJT. On the 2 occasions when I gave evidence to a BOI, my technical ability and use and availability of documentation was queried, and the BOI satisfied, but formal training qualifications were never raised as an issue or contributory factor.
Standards
Thank you those who are more up to date than I.
There is a formal 'Order of Preference or Hierarchy for the Selection of Standards for MoD Acquisition'. My copy pre-dates the MAA, but Defence Standards sit above UK MoD Departmental Standards and Specifications. I don't have a copy which says where the MAA documents sit.
In aviation, this was complemented by Controller Aircraft Instructions, mandated upon every member of Air Systems Controllerate. The 05-Series of Procedural Defence Standards were mandated in every aviation contract. This was the one area where Def Stans sat above 'Recognised Industry Standards'. Which is just another way of saying what others have confirmed.
What was immediately obvious to me when the MAA started producing all this 'regulatory set' was, in key areas (e.g. maintaining the build standard, which is what would have avoided so many deaths) their words reflected, almost word for word, the aborted Chief of Defence Procurement Instructions (CDPIs) from 1993. The MAA made precisely the same mistake in its definition, and immediately went off at a tangent. As far as I know, this is still the case (based on a word search of key words). The problem was, the money had already been withdrawn to maintain the perfectly good 05-Series Def Stan, and eventually it was scrapped. So, today there are no laid down procedures that industry agree with. It might accept a contract lacking it, but I'll lay money its engineers have a copy of the Standard in their top drawers. Both Parts. I'd lay more money on MoD not being able to produce Part 2 at all, and only having an old version of Part 1, at best. That Standard was not written or issued by ADRP. It was written and maintained by the Technical Agencies I mentioned earlier. My old boss's name is still in my copy, promulgating the last update - which we had written to reflect changes in legislation.
This all may sound faffy, but it is the foundations upon which the safety aircrew take for granted are laid. Its money in the bank and costs peanuts to implement, because the work is not volume-related. You know within a very small margin how much the annual cost is. Getting it wrong costs an awful lot more, and not just after an accident.
There is a formal 'Order of Preference or Hierarchy for the Selection of Standards for MoD Acquisition'. My copy pre-dates the MAA, but Defence Standards sit above UK MoD Departmental Standards and Specifications. I don't have a copy which says where the MAA documents sit.
In aviation, this was complemented by Controller Aircraft Instructions, mandated upon every member of Air Systems Controllerate. The 05-Series of Procedural Defence Standards were mandated in every aviation contract. This was the one area where Def Stans sat above 'Recognised Industry Standards'. Which is just another way of saying what others have confirmed.
What was immediately obvious to me when the MAA started producing all this 'regulatory set' was, in key areas (e.g. maintaining the build standard, which is what would have avoided so many deaths) their words reflected, almost word for word, the aborted Chief of Defence Procurement Instructions (CDPIs) from 1993. The MAA made precisely the same mistake in its definition, and immediately went off at a tangent. As far as I know, this is still the case (based on a word search of key words). The problem was, the money had already been withdrawn to maintain the perfectly good 05-Series Def Stan, and eventually it was scrapped. So, today there are no laid down procedures that industry agree with. It might accept a contract lacking it, but I'll lay money its engineers have a copy of the Standard in their top drawers. Both Parts. I'd lay more money on MoD not being able to produce Part 2 at all, and only having an old version of Part 1, at best. That Standard was not written or issued by ADRP. It was written and maintained by the Technical Agencies I mentioned earlier. My old boss's name is still in my copy, promulgating the last update - which we had written to reflect changes in legislation.
This all may sound faffy, but it is the foundations upon which the safety aircrew take for granted are laid. Its money in the bank and costs peanuts to implement, because the work is not volume-related. You know within a very small margin how much the annual cost is. Getting it wrong costs an awful lot more, and not just after an accident.
Tucumseh, these RA's might be applicable to that area, although the manner this was complied with on one platform was much to be desired and initally added not a lot to safety/airworthiness:
https://www.gov.uk/government/upload...70_Issue_2.pdf
https://www.gov.uk/government/upload...71_Issue_2.pdf
https://www.gov.uk/government/upload...72_Issue_2.pdf
https://www.gov.uk/government/upload...74_Issue_2.pdf
As in previous post, the qualification requirements laid down within these RA's were not fully complied with when positions were originally staffed, probably due to the lack of SQEP's available to fulfill the posts when the requirements were first laid down.
I will leave it up to others more current on this to decide if this has been sorted, though I still think the implementation, and a word I hate, i.e interpretation, of the regulations is still letting safety incidences slip through in all the confusion.
Sorry forgot this one:
https://www.gov.uk/government/upload...73_Issue_2.pdf
https://www.gov.uk/government/upload...70_Issue_2.pdf
https://www.gov.uk/government/upload...71_Issue_2.pdf
https://www.gov.uk/government/upload...72_Issue_2.pdf
https://www.gov.uk/government/upload...74_Issue_2.pdf
As in previous post, the qualification requirements laid down within these RA's were not fully complied with when positions were originally staffed, probably due to the lack of SQEP's available to fulfill the posts when the requirements were first laid down.
I will leave it up to others more current on this to decide if this has been sorted, though I still think the implementation, and a word I hate, i.e interpretation, of the regulations is still letting safety incidences slip through in all the confusion.
Sorry forgot this one:
https://www.gov.uk/government/upload...73_Issue_2.pdf
Last edited by Exrigger; 28th Feb 2018 at 13:02. Reason: Forgot RA
For those interested here is the Def Stan list, 05-61 Quality was one I remember being in company contracts, there were others, but have been out of the loop for a while, even renewed contracts seemed to hang onto some that were obsolete, but nobody seemed bothered, even some in the military did not know that ones they quoted were obsolete.
https://www.dstan.mod.uk/StanMIS/Ind...fenceStandards
https://www.dstan.mod.uk/StanMIS/Ind...fenceStandards