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Martin Baker to be prosecuted over death of Flt Lt. Sean Cunningham

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Martin Baker to be prosecuted over death of Flt Lt. Sean Cunningham

Old 2nd Mar 2018, 11:37
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EAP86

Here's what I would have done.

1. Assess H-C's recommendations (i.e. relating to systemic failures) What single process would have prevented them? (Same answer for most)
2. Question to all PTs. Are you maintaining the Build Standard?
3. Answer (invariably) - No. We're taught it's a waste of money. We just sign to say we've done it to get the likes of you off our backs.
4. Issue reminder of legal obligations.
5. New print run of mandated Def Stan, copy to every individual. Read, inwardly digest. Practical examinations before being allowed in any DE&S / MAA engineering post. Keep on your desk at all times.
6. Sack those who still think it a waste of time.
7. MAA recruitment drive to replace sacked senior staff.
8. Update MAA regulatory set, as it gets the basic definition of the overarching process completely wrong.

Tongue not entirely in cheek.
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Old 2nd Mar 2018, 15:43
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Originally Posted by RetiredBA/BY
Perhaps you misunderstood or I did not make myself clear.
What I meant is that the seat pin should be left in place after landing, IN ITS FLIGHT STOWAGE until the pan is reached, engine shutdown and then carefully replaced with visual observation, by the occupant, of correct insertion, NOT doing it by feel during taxi in when eyes should be outside particularly with other aircraft in close proximity.

That’s the way it was done during my time 12 years on ejection seats and I still feel it is the safer and better procedure.

That was on mk2, 3 & 4 seats so perhaps there are good reasons, no one has yet explained, that the Mk10 has to be different.
Much clearer - that is the procedure on Tornado, unless you’re parking in somewhere like a RES (an aircraft shelter you taxy into forwards). In that case you’d pin up before entering for the obvious reason.
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Old 2nd Mar 2018, 21:45
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Reader8,
The 'say yes and get on' problem is a real killer of airworthiness issues and regulatory progression. Mainly caused, as you imply, by the short-tour officers in a very largely influential post. It is these career-minded idiots that risk many peoples lives by their Trump-like decisions, but borne out of promotion targets and their next tour.

Tuc,
Your example relies on honest answering...not a prominent trait in many MOD/RAF positions, in my experience - See Eng Os actions in my previous post and the above statement.
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Old 2nd Mar 2018, 22:34
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Rigga, cracking post! Short, sweet, and succinct, yet it contains all that has gone wrong with UK Military Airworthiness, why it went wrong, and who is responsible for making it go wrong.

We need to keep our eye on the woods for fear of getting obsessed with the various trees. This tragedy, and every other tragedy featured in UK Military Airworthiness Related Fatal Accident threads on this forum, are all connected by the dysfunctional system that you highlight. RAF VSOs have been the downfall of an Air Safety System that used to be an international leader. Now it simply adds victim after victim to its death list, and hacks away at the very vitals of UK Air Power. The VSOs responsible are protected by a cover up that inhibits reform of both Regulator and Investigator. Whether the RAF is prepared to clean out its own stables is for it to decide. What cannot be allowed to continue is the baleful effect its leadership has on UK Military Air Regulation and Investigation. Both must be removed from its influence and made independent of the MOD and of each other.

This has to be faced up to now and the nettle grasped. Aviation doesn't tolerate a dysfunctional system and tends to be merciless in response. We need to be equally merciless and stop this rot now!
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Old 3rd Mar 2018, 07:36
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Rigga

Your example relies on honest answering...not a prominent trait in many MOD/RAF positions
But it helps if you already know the answer! I've stood in front of an entire IPT and heard #3. The only person who actually understood the question and agreed with me used to work in Directorate of Air Armaments. Another defensive barrier that has disappeared.
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Old 3rd Mar 2018, 09:04
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The 'say yes and get on' problem is a real killer of airworthiness issues and regulatory progression. Mainly caused, as you imply, by the short-tour officers in a very largely influential post. It is these career-minded idiots that risk many peoples lives by their Trump-like decisions, but borne out of promotion targets and their next tour.

Tuc,
Your example relies on honest answering...not a prominent trait in many MOD/RAF positions, in my experience - See Eng Os actions in my previous post and the above statement.
In all honesty you can apply that to some within the civilian companies that are trying to work to the same regulations, and have to engage with these military versions described by Rigga, one example when trying to get a Squadron JENGO to follow the regulations, his response was "You civilians just don't understand how the military system works", in fairness some did not, but this only emphasised how little he and others in the military, with a similar view, actually know about 'their regulations'.
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Old 3rd Mar 2018, 09:19
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ER:-
when trying to get a Squadron JENGO to follow the regulations, his response was "You civilians just don't understand how the military system works"
The response to which is, "Well neither do you!".

The "system" that he knows is a sham. The system that he has been taught is a corrupt and dysfunctional one. The system that he should have been taught was destroyed in Haddon-Cave's "Golden Period", deliberately and with malice by RAF VSOs. As a result he is a liability, not an asset. He is now part of the problem.

As to civilian companies (including MBA) having difficulty coping with this shambles, of course they do! Who wouldn't? But it is the Military who created the shambles and it is they who should face up to the reality, stop the cover up, and co-operate in the reform of UK Military Airworthiness and Accident Investigation by both becoming truly independent of the MOD and of each other.
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Old 3rd Mar 2018, 09:45
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Chugalug2, agree up to point, having dealt with said JENGO in a similar manner to what you suggested, though it was a couple of RA's that he reckoned only applied to the civilian companies, not to the military, by that attitude the squadron/station were causing an issue for the civilian companies and risking their compliance/approval, again he learnt the error of that view eventually.

Yes the civilian companies do have problems coping with the military system shambles, but there were still those that went with the flow of the military view just to make sure the contract/approvals were not put at risk, or avoid any come back on them, and lastly to make their days easier.

The net effect is a buggers muddle that won't stop accidents and incidences until the message gets through to the 'management' that they cannot keep changing things and then not follow those very regulations, whichever ones they finally hang their hats on, that are supposed to prevent these very things from happening.
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Old 3rd Mar 2018, 10:58
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ER:-
but there were still those that went with the flow of the military view just to make sure the contract/approvals were not put at risk, or avoid any come back on them, and lastly to make their days easier.
I don't doubt it, bad apples and all that, but like your JENGO they are symptoms of the problem rather than its cause. The problem is the UK Military Air Regulator itself, staffed as it is by many who were complicit in creating or covering up this scandal. It is fatally compromised by its inability to acknowledge what really happened, who were really responsible, and instead clings to the fiction of the Haddon-Cave "Golden Period".

No matter how many new regulations the MAA dreams up, UK Military Airworthiness will remain the buggers muddle that you so aptly term it. Nothing short of a root and branch reform will suffice, starting with replacing the MAA and the MilAAIB (or whatever the sign outside reads this week) with truly independent civilian led versions. Now this may bring to mind the words Turkeys and Christmas, but anything less will simply prolong the agony, cost yet more life and treasure, and further compromise our national security.
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Old 3rd Mar 2018, 11:08
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starting with replacing the MAA and the MilAAIB (or whatever the sign outside reads this week) with truly independent civilian run versions
That won't happen when a lot of the military currently blame civilian contractors for all their issues in the first place, and secondly they don't think it is broken, which is the most dangerous issue with it all.
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Old 3rd Mar 2018, 11:08
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DV I'm assuming that this is a real question, not rhetorical. I can only speak from an industry perspective but having had many discussions on ALARP with members of the MAA, it may be helpful.

We were advised (by legal qualified officers) that in the event of an accident and consequential court action, any safety determination we had made could be expected to be investigated by the likes of the HSE or courts to establish whether the legal criteria had been met.
Yes, it was a real question, because since the introduction of RA 1210 not one ODH has appeared in court, or at an inquest. The way I read the regulation, in the case of the Red Arrow accident, the AOC 22 Group should have appeared at the inquest and justified how his platform (and seat) met the tolerable and ALARP criteria that he had signed off on.

DV
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Old 3rd Mar 2018, 11:20
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Exrigger,
"In all honesty you can apply that to some within the civilian companies that are trying to work to the same regulations"

That principle, in civilian companies, is generally evaded by the incumbent being a specialist in a particular field, not having any other predetermined place to go for a good few years, if ever, and who is paid for his performance in that position, not for his title regardless of performance.

In my lowly opinion, most RAF officers don't know how their 'system' works. Like their mechanics/technicians, they were taught it at school but it is beaten out of them as soon as the arrive in a real post where "we dont do it like that here" comes into play. If they dont play along they get the boot.

At Station levels the RAF is only interested in their next sortie(s). This tunnelled vision practice excludes ALL other influences from their Silo (Squadron) in which they concentrate their efforts. OCs, ENGOs and JENGOs are there solely to allow the next sortie to be flown. This is fine in times of war/conflict but has no airworthiness point at all. And my point here is that it is fine in times of war! In the UK we are not at war...I have my response for those that say we are...

One of my questions to the customer, to try and understand their duplicity in maintenance, was "Why did the RAF ban BDR Techniques because they were deemed unsafe but then allow, and even quietly promote, the ignorance of 'mandated' procedures in maintaining their aircraft?" No reply...
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Old 3rd Mar 2018, 11:50
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That principle, in civilian companies, is generally evaded by the incumbent being a specialist in a particular field, not having any other predetermined place to go for a good few years, if ever, and who is paid for his performance in that position, not for his title regardless of performance.
My observation earlier must have been misplaced when I said we had worked under the same people just different platforms, as there were quite a few that your observation did/does not apply to, some thankfully were moved, some are in the same post but different platform and has not changed their outlook, and I would still say that your comment below applies to some within the civilian world from my experience, that is all I am saying, neither which helps sort the mess the military have got themselves into, as I said earlier they don't accept it is broken and untill they do, nothing will change and fully agree with what you have written which supports my views and experience:

most RAF officers don't know how their 'system' works. Like their mechanics/technicians, they were taught it at school but it is beaten out of them as soon as the arrive in a real post where "we dont do it like that here" comes into play.
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Old 3rd Mar 2018, 13:22
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ER:-
they don't think it is broken, which is the most dangerous issue with it all.
Absolutely bang on! My perpetual, irritating, and very annoying slogan is;

Self Regulation Doesn't Work and in Aviation It Kills!

You sum it up more succinctly and convincingly than I, so thank you! Here we have the dilemma that the very people who need to take urgent life saving action are instead in total denial. They may well be judge and jury of their own case, but there are others above them in Government, Parliament, the Judiciary, Law Enforcement, who have the power to bring them to task and demand changes. Unfortunately each of those institutions have singularly failed to date in their duty to do so, often taking direction from the MOD for their inaction. That is the extent of this scandal, that is what has to change.

Of course it is easier to roll over and say that, "It just ain't going to happen". My answer is that it has to. The RAF cannot ground any more fleets, it cannot accept the unairworthiness infecting its aircraft, it cannot go on protecting certain VSOs at the cost of others' lives, without fatally affecting its operational raison d'etre, to defend our skies and to deny them to our enemies.
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Old 3rd Mar 2018, 14:16
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Originally Posted by Rigga
Exrigger,
"In all honesty you can apply that to some within the civilian companies that are trying to work to the same regulations"

That principle, in civilian companies, is generally evaded by the incumbent being a specialist in a particular field, not having any other predetermined place to go for a good few years, if ever, and who is paid for his performance in that position, not for his title regardless of performance.

In my lowly opinion, most RAF officers don't know how their 'system' works. Like their mechanics/technicians, they were taught it at school but it is beaten out of them as soon as the arrive in a real post where "we dont do it like that here" comes into play. If they dont play along they get the boot.

At Station levels the RAF is only interested in their next sortie(s). This tunnelled vision practice excludes ALL other influences from their Silo (Squadron) in which they concentrate their efforts. OCs, ENGOs and JENGOs are there solely to allow the next sortie to be flown. This is fine in times of war/conflict but has no airworthiness point at all. And my point here is that it is fine in times of war! In the UK we are not at war...I have my response for those that say we are...

One of my questions to the customer, to try and understand their duplicity in maintenance, was "Why did the RAF ban BDR Techniques because they were deemed unsafe but then allow, and even quietly promote, the ignorance of 'mandated' procedures in maintaining their aircraft?" No reply...
Interesting points made, multiriggas.

IMHO In the 80s and early 90s the practice of EA staff officers on 'short' tours, unashamedly getting career path 'ticks in the box' was a major contributor to what followed. I was in EA and EA related staff jobs for 15 consecutive years. (and, as a WO, despite that I had NO formal staff training at any point - I hit the ground running) From personal experience, even a good SO2 or SO3 grade posted in would take the best part of a year to 'learn the ropes'. (None of them were specialists) We would probably then get 9 months productive work before their minds were on their next career move.

Driving down 'Airworthiness responsibility' by delegation to those (SO2/3) levels was (again IMHO) ill advised, to say the least. There was no stability, and I suspect that the quality of the staff officer output throughout was probably linked with personal career pattern and prospects. It certainly meant that stress levels amongst us 'pond life' were kept extremely high.

I thoroughly enjoyed my time in staff work, but the historical airworthiness related issues, which went on way above my pay grade of course and covered at length here, leaves me extremely sad.
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Old 3rd Mar 2018, 15:07
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OMS, your timescale and mine differ by some years. You: 80's to 90's. Me: 2010-2014.

But we have both seen the same practices, and shown our concerns, indicating the longevity of error and continuance of this folly from the pre-H-C era into the so-called 'new' MAA.

As in many civil companies when a new management takes over; all that really happens is the Coveralls that staff wear change colours. So the same old practices are still in place in the 'new' MAA organisation.

"If nothing changes, it'll stay the same." Tern Hill, ASF toilet, 1970's....(it made me laugh then!)
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Old 3rd Mar 2018, 16:30
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Yes R, we do differ in timescale. I started in EA staffwork in 85 and left the service in 01, but the decline really started around 90 time, and each cut was usually billed as an 'efficiency measure'. From my perspective the constant chopping of budgets merely to massage an ego or two ("look at how much I've saved") didn't help. For example. In '85 I can recall writing my own STIs and SIs (titles in old money) content that top cover was there in the form of many levels of scrutiny and approval I would need to circumvent on the way to publication. I was also more than happy that I could convince those in the chain that my instructions were safe, sensible and practical. Regular contact with DAs via LTCs and Mods committees chaired by PE made sure of an auditable and seamless record of activity.

I gather most of those checks and balances have now disappeared. Some efficiency measure that?
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Old 3rd Mar 2018, 21:18
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Originally Posted by Distant Voice
The way I read the regulation, in the case of the Red Arrow accident, the AOC 22 Group should have appeared at the inquest and justified how his platform (and seat) met the tolerable and ALARP criteria that he had signed off on.
DV,

Unfortunately the HSE chose not to charge any of the DHs (or other MOD individuals) involved and, of course, they cannot take the MOD to court. BTW the 'tolerable' bit of 'tolerable and ALARP' isn't part of UK law, just part of the MAA's regs. I'd expect the court to interrogate witnesses about previous safety incidents and what was done to fix any failings arising. If the witness cannot answer with details showing that they did everything they reasonably could to prevent recurrence, they may be in some trouble. A Solicitor once told me that the best layman's definition of ALARP is "what would you tell the Judge?"

EAP
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Old 3rd Mar 2018, 21:26
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OMS, well done for doing the full whack.
I have no concept of the workings of an EA/PTL except (2010-2014) those I dealt with who didn't very much in the way of Maintenance Programme updates (Maintenance Schedule updates) apart from reacting to emergent issues warranting their attention.

I was a rigga from 75-99 and I've worked in airline and MRO quality and continued airworthinesss management since then. As an "aviation" Quality Manager I never touch ISO9001 (QMS is not a legal requirement) so I concentrate on regulations and practices to cut costs in a legal and risk averse fashion.
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Old 4th Mar 2018, 07:04
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Originally Posted by Rigga
Reader8,
The 'say yes and get on' problem is a real killer of airworthiness issues and regulatory progression. Mainly caused, as you imply, by the short-tour officers in a very largely influential post. It is these career-minded idiots that risk many peoples lives by their Trump-like decisions, but borne out of promotion targets and their next tour.
I only met two that were career minded in the sense that you felt inconvenient truths were just being kept close hold, and one definitely wasn't an idiot.

The others weren't career minded idiots, they were good people. They wanted and needed to get on, but falling on your sword, even at EA level, is frankly unlikely to cause more than a small stir as a new EA is found. It's more nuanced. If they don't do it somebody else will. They understood the issues but found themselves in an impossible situation inside an organisation with a deeply flawed culture where staffwork and a good thesaurus were the answer to all problems (The rest of the world does it another way, but why let that concern the path were on). The nub of the problem didn't really lie with the EA anyway, it lay with the customer who knew that they had to fly the things. Many problems were of the customers own making (how many E3's in the green today, what did we tell the Minister last year) and required an ever deeper hole to be dug, some were frankly down to the awful politics of everything at that level, and the fact that the Sun is equally happy to write about things not being pushed far enough (Aircraft grounded in RAF Chaos, there's a war on don't-ya-know) as they are when disaster strikes.

In the end, I just felt that it was 'Yes Minister's writ large, and everybody actually relaxed when the truth was told and they knew where they were.


Unfortunately, that was rarely where the MAA wanted them to be, but that's just another side of the same coin that's significantly unbalanced in weighing resources against tasks against aspirations.

It's quite possible that there was genuinely somebody at the top who was longing to hear the problem and truly accepted that termination was an option. I never had the impression that anybody at 1* level was keen to test the hypothesis, which gives those at the top a perfect get-out (Yes your honour, of course I would have stopped straight away, had I only known). Yeah, right.

For all people can hand-wring about RA's, EA's and DH's the reality from my viewpoint was that they were window dressing to the root cause, which was the naked emperor that is the cause of most good staffwork in non-operational matters.

I didn't envy the DH.

Last edited by reader8; 4th Mar 2018 at 07:32.
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