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

[tucumseh]

I didn't envy the DH.

This entire 'construct' is, I believe, flawed for a number of reasons. Today's 'Duty Holders' are unlikely to understand or have experienced how to actually deliver and maintain airworthiness. They may know small bits of it, but are more likely to have an inkling about Fitness for Purpose. You can see this in the MAA's regulatory set, which to a large degree concentrates on FFP to the exclusion of the pre-requisites.

The last time I spoke to a senior officer in the MAA, he didn't understand the difference; which was also evident at the C-130 XV179 Inquest in 2008, when the IPTL simply hadn't a clue about his primary role. He didn't say 'of course I would have stopped straight away, had I only known'. He simply denied that he had anything to do with it; and even if he knew what to do, he wasn't allowed to. The families were left wondering who the hell was responsible. The implication was it was all the fault of some junior officer out in Iraq who, somehow, was meant to go and buy some Explosion Suppressant Foam and stuff it in fuel tanks. That's not criticism of either officer. Nothing in their background prepared them for their roles. Nothing has changed.

Engineering Authorities (by which I mean SNCOs and junior officers) are more likely to understand quite a lot about all three areas. I always found the EAs in all three Services superb. But, reader8, you are right in saying very few would speak out, especially when (by definition) you're complaining about a VSO. Slightly easier for civilians, but MoD personnel policy has effectively got rid of any experience.

[reader8]

Originally Posted by tucumseh

This entire 'construct' is, I believe, flawed for a number of reasons. Today's 'Duty Holders' are unlikely to understand or have experienced how to actually deliver and maintain airworthiness. They may know small bits of it, but are more likely to have an inkling about Fitness for Purpose. You can see this in the MAA's regulatory set, which to a large degree concentrates on FFP to the exclusion of the pre-requisites.

The last time I spoke to a senior officer in the MAA, he didn't understand the difference; which was also evident at the C-130 XV179 Inquest in 2008, when the IPTL simply hadn't a clue about his primary role. He didn't say 'of course I would have stopped straight away, had I only known'. He simply denied that he had anything to do with it; and even if he knew what to do, he wasn't allowed to. The families were left wondering who the hell was responsible. The implication was it was all the fault of some junior officer out in Iraq who, somehow, was meant to go and buy some Explosion Suppressant Foam and stuff it in fuel tanks. That's not criticism of either officer. Nothing in their background prepared them for their roles. Nothing has changed.

Engineering Authorities (by which I mean SNCOs and junior officers) are more likely to understand quite a lot about all three areas. I always found the EAs in all three Services superb. But, reader8, you are right in saying very few would speak out, especially when (by definition) you're complaining about a VSO. Slightly easier for civilians, but MoD personnel policy has effectively got rid of any experience.

Yup, agree. One Pprune post can't characterise a whole system that's flawed from the guy on the 18 month ground tour deciding what to buy onwards. Plus the relative anonymity allows one to discharge both barrels.

I would say that it should be the job of the staff to educate the VSO. It's the job of the VSO to take the time to listen and understand when they are paid handsomely for the responsibility they hold. Too many complain about "too much detail" or "this is confusing" to give me a great deal of sympathy (although to be fair to them, it's often their staff laying that foundation for whatever agenda they may or may not have understood from the VSO, as I said, relentless politicians). These two phrases are dispatched by the VSO with a well practiced body language which either says 'tell me more' or 'STFU'. When it's STFU time, maybe they don't understand, maybe they don't want to. I think that if you can't tell the difference you still have problems. There are not many aircraft types and plenty of senior officers to go around.

I did occasionally see a DH simply listen to opposing viewpoints, allow both sides to frankly express views and then give homework and accept risk. It shouldn't come to that, but at given the, as you say, FFP nature of the whole thing it often did. Unfortunately, that behaviour was the exception not the rule.

Of course, depending on the structure of the acquisition the DH may not be able to do much anyway. Take P8 or F35, if there's something the Brits don't like, surely tough if there's a CBA to be done for a global fleet.

At least the front line knows, by-and-large, how to actually operate the thing. Civil aviation breeds experts, we generally don't. People can become so, but when they do the service can't take advantage of that

DE&S are supposed to be the answer, they're not. Again, rarely personal, just a system that doesn't work right.

If it all seams like a bit of a perverse characature, that's because it can be! Safety in terms of airworthiness is best achieved through compliance with recognised practice at the lowest level possible. When that doesn't happen, regardless of whether the problem is in materials used, designs embodied or redundancy provided, things go wrong answering the only question there is "but what does that mean".

[oldmansquipper]

This thread has been enthralling.

It seems that most posters (since the judgement anyway) are in broad agreement over the myriad causes of this tragic incident. We all understand there is/was 'something rotten in the state of Denmark', but what can be done about it? I really still cannot see the EA equivalents of today (SNCOs and Junior desk Officers) getting much joy from taking their concerns to their VSOs. I would love to be wrong.

IMHO, It is particularly poignant that the family of those poor people killed in the Grand Canyon helicopter crash recently are taking both the owners and the aircraft manufacturers to court over their failure to fit (if that's the right word) fire suppression to the fuel systems. I doubt that those responsible for that one will be able to 'hide' in this civil case.

So what, in your opinions, is an achievable 'way ahead' for UK Military Aviation, such that is left of it?

Answers in simple terms please - and not too many abbreviations etc ....

[Shackman]

OMS,

Just as a small aside - it is the fitting of a 'plastic' fuel tank that is believed to be the problem in the Grand Canyon accident: the same one fitted to all the DHFS squirrels.

And I agree, the thread makes fascinating (or should that be frightening) reading, particularly those inputs from Tuc, Chug 2 and Rigga, but also beggars the question 'why did MB roll over?' Or have I missed something

[oldmansquipper]

I think some of the passengers survived the initial impact but suffered severe burns before or during egress and passed away later. It was a ticker tape headline on Sky meejah yesterday. Fuel suppressant issues feature heavily in the airworthiness discussions earlier in this thread.

[oldmansquipper]

Originally Posted by Shackman

OMS,

Just as a small aside - it is the fitting of a 'plastic' fuel tank that is believed to be the problem in the Grand Canyon accident: the same one fitted to all the DHFS squirrels.

And I agree, the thread makes fascinating (or should that be frightening) reading, particularly those inputs from Tuc, Chug 2 and Rigga, but also beggars the question 'why did MB roll over?' Or have I missed something

thanks I take your point on the plastic tank, however fuel suppressant discussions (and the lack of airworthiness action to implement protection) feature heavily in many of the posts in this thread. As for why MB rolled over? A very good question which also deserves an answer.

[EAP86]

Originally Posted by oldmansquipper

So what, in your opinions, is an achievable 'way ahead' for UK Military Aviation, such that is left of it?

The MAA paid quite a lot of attention to adapting the civil regs to the UK military context but I feel they missed a fundamental point: in the civil system, the obligations are placed on those with the technical competence to make the right judgments. You have to use these people wherever they are to be found (irrespective of rank or organisation). Tuc has often drawn our attention to the CS process for gaining competence. While I agree wholeheartedly with his views, I doubt whether that process can be recreated in the medium term.

Originally Posted by oldmansquipper

As for why MB rolled over? A very good question which also deserves an answer.

Just my opinion. Companies exist to deliver commercial success. Maybe MBA and their insurers decided that rolling over was the most effective way to return to commercial success?

EAP

[NutLoose]

Unfortunately, at least in my experience, the level of 'air safety' or indeed airworthiness, an organisation achieves is not at all related to the amount of regulations it tries to obey. I once chaired a meeting where we aimed to take a 'first pass' at comparing RN and RAF aircraft operating and maintenance regulations. The RN guys came in with four or five books. I am not making the next bit up. The doors swung open, and our RAF colleagues pushed in a large four wheeled trolley loaded up with many tens of volumes. Note - these were the non aircraft specific regulations.

I for one am a great believer in keep it simple, I always have believed that burdensome legislation is not and never has been the way to go forward, It hampers those trying to achieve airworthiness whilst no matter how much paperwork you produce, those that failed to carry out such work previously are never going to do so simply because you have produced more rules.

In an ironic twist, EASA in their quest to make light maintenance "simpler" (read.. push responsibility off their shoulders and onto others) have pushed it on individuals to produce their own maintenance programmes for their aircraft, this has resulted in each individual aircraft of each individual type having a different maintenance programme, where as before you operated to a generic one size fits all that covered the basics, thus ensuring safety and a minimum standard. Now it is in my eyes cost driven.

[reader8]

Originally Posted by oldmansquipper

I really still cannot see the EA equivalents of today (SNCOs and Junior desk Officers)

To be clear, each airframe has an EA, a Senior Officer who holds an LOA to allow him or her to act as such. These aren't SNCO or JO failures. The EA role is still staffed by somebody who should be SQEP to act as such.

[oldmansquipper]

Originally Posted by reader8

To be clear, each airframe has an EA, a Senior Officer who holds an LOA to allow him or her to act as such. These aren't SNCO or JO failures. The EA role is still staffed by somebody who should be SQEP to act as such.

Sorry, I meant the guys at desk level who did the donkey work back in the day. I accept that the entire dept was the "EA (Engineering Authority)" IIRC ours was headed up by a SO1 (Wg Cdr) level who reported to the DD (a GC) by the time I left the first EA I was in, the Wg Cdr was in fact a Supply Branch officer. However, I recall going for guidance to one of my earlier Wg Cdrs (this time an Engineer) with a particularly 'difficult' issue, his response was, and I quote "oh, er, just keep all the balls in the air for a while, I am posted next month"

Clearly not SNCO/JO failures

[Chugalug2]

The problem was never the lack of regulations, they more than ensured that UK Military Airworthiness was fully functional and effective, provided they were implemented. And so they were, until the RAF equivalents of Pol Pot ordered that they be suborned, ie signed off as complied with but not implemented. Those trained and experienced engineers whose work it was to provide for airworthiness were now immediately faced with a moral dilemma, to defy what were clearly illegal orders or comply, with all that would entail. Those who complied ensured that there was an immediate break in the continuous process of audit that is the cornerstone of airworthiness. Without it even the most simple aircraft are rendered unairworthy and so the ACO gliders were grounded... sorry paused in consequence, albeit only eventually. Those who defied the order were hounded, persecuted, appealed, only then to have it confirmed by ministers that the orders were proper and that defying them was an offence. Eventually those square pegs were replaced by compliant inexperienced untrained non-engineers. The corporate knowledge was lost, the regulations pulped, and year zero heralded the infamous H-C Golden Period.

No amount of reinventing the wheel will avoid a repeat of this scandal happening again. You may well ask why RAF VSOs should want to subvert the airworthiness of their own aircraft. Of course, they did not. All they wanted was to release the historically ring fenced Air Safety monies to plug a gaping hole in the supply budgets, not caused by government cuts but by the ineptitude of RAF VSOs. The problem was not why but how, and it was all too easy as they outranked anyone who might seek to stop them, or reveal what had happened, or that certain resultant fatal accidents were airworthiness related. In short they did what they did because they could. Civilian Operators would no doubt do the same given half a chance, so they are denied it by having an independent regulator and investigator.

OMS, you ask what is to be done? I say do the same as the civilians. Nothing less than an independent regulator and investigator will suffice, lest history repeats itself (it oftimes does you know).

[tucumseh]

EAP86

I doubt whether that process can be recreated in the medium term.

Or long term, as it requires will. There is no longer a natural recruitment ground, as our workshops have been privatised. This contributes to the fact that most CS 'engineer' recruits don't realise they're skipping five grades. That's a lot of learning and experience missing. While they get on with their job, neither they nor their bosses understand what is NOT being done.

[tucumseh]

reader8

SQEP

Has this term ever been defined by MoD? I know it defined 'inexperience' in the context of engineering programme manager (which, to a civilian, is something you do after EA, ILS Manager, Requirements Manager - or used to be!). 'Qualified' to, say, CEng, wouldn't have helped Flt Lt Cunningham. One thing that would have saved him was someone who'd listened to his first lecture on threaded fasteners and how to fit them, could read the regulations he was given a personal copy of, and passed a practical trade test.

[dragartist]

Originally Posted by oldmansquipper

Sorry, I meant the guys at desk level who did the donkey work back in the day. I accept that the entire dept was the "EA (Engineering Authority)" IIRC ours was headed up by a SO1 (Wg Cdr) level who reported to the DD (a GC) by the time I left the first EA I was in, the Wg Cdr was in fact a Supply Branch officer. However, I recall going for guidance to one of my earlier Wg Cdrs (this time an Engineer) with a particularly 'difficult' issue, his response was, and I quote "oh, er, just keep all the balls in the air for a while, I am posted next month"

Clearly not SNCO/JO failures

When I joined SM65 (WPNS) sometime after you. My LOA was issued by the GpCapt. The WgCdr Stacker was out of the loop on all things Engineering. We tended to leave him sat in the corner orchestrating his release or managing his stocks and shares. The WOs who worked for me did not have LOAs.

[oldmansquipper]

IIRC, LsOA (letters of authority???) started to appear in the very early 90s as the 'EA' Morfed into a MDG, and then into a SA and IPT. My direct boss at the time was an Electronics S/L on retention. Excellent chap, very knowledgeable and eager to learn about my specialisation. On the other side of the office was a very capable and bright F/L. These two guys were very good (not all their predecessors had been) but I'm sure they were both frustrated as I was by the salami slicing that was going on. As you so rightly pointed out, WOs were never given 'delegated authority' and the responsibility for rubber and leatherware was delegated to them. So I guess they must have received their delegated LsOA shortly after I left but before SM65 moved up to Wyton.

I remember being surprised that final responsibility was being driven down to the level it was. It didn't make a lot of sense unless abrogation of responsibility on high was the aim all along. But what did I know?

[NutLoose]

One thing that would have saved him was someone who'd listened to his first lecture on threaded fasteners and how to fit them, could read the regulations he was given a personal copy of, and passed a practical trade test.

I think that is rather unfair, If there is nothing to say the shackle should not be tightened down then the natural assumption would probably be to tighten it. The problem lies not with the person tightening it, but with the flawed design that allows it to happen in the first place.. I see poorly designed items day in day out and some actually assembled incorrectly by the manufacturers, because the design and the information are not there to prevent it.

[Engines]

Nutloose,

I'm really sorry, but I have to refer you back to my post 463 on this thread.

The RAFAT's arrangements for servicing ejection seats was, in my honest view, a shambles. No proper training, lack of experience, documented malpractices, all found by the SI. Add on to that a culture of abbreviated timescales, 'bespoke' routines, and an RTI that, again in my own view, should never have been issued, all combined to put this pilot in danger's way.

The over tightening of the shackle (and since when has cutting new threads into a bolt been 'accepted engineering practice'?) was just another link in the accident chain. Despite what I've said, I would not have harshly criticised the man who turned the spanner that day. I'd have started with his supervising NCOs, moved up the chain to the EngOs, asked the SEngO why his unit was being so cavalier with ejection seats, then asked the OC Eng what his safety and QA cell was doing to make sure that ejection seats (which are hazardous by their very nature) were being properly serviced.

And by the way, I wouldn't have asked very nicely.

The tragedy here is that, as Tuc as pointed out so many times, the main problem here wasn't lack of regs, or incomplete instructions. The main problem was a comprehensive failure to apply well known and extant regulations to control, manage and implement safe servicing of an ejection seat. And that failure took place within DE&S and the RAF.

Could the shackle design have been improved? Possibly. Were there shortcomings in the documentation? Probably. But if you give poorly trained, inexperienced personnel the responsibility for frequently disassembling and reassembling a safety critical item on an ejection seat, they you are creating a far bigger risk that MB ever did.

Best regards as ever to all those working so hard to keep our people safe,

Engines

[NutLoose]

I didn't realise he had rethreaded the bolt.

[tucumseh]

It is worth reminding ourselves that when Martin-Baker issued SIL704 after the accident, part of the reason was they were under new instruction from MoD to remove the assumption that RAF engineers would be adequately trained.

Hitherto, they had been instructed to assume a certain degree of training that would, for example, ensure maintainers didn't cut new thread and knew that the Drogue Shackle had to be free to move. The RAF Director of Flight Safety warned the Chief Engineer and ACAS about this very problem in 1992. That, maintainers were being held 'hostage to fortune'.

[NutLoose]

to remove the assumption that RAF engineers would be adequately trained.

Remind me never to fly in a service aircraft ever again. That is frightening in the extreme. Looking at the current course lengths they are under half the length mine was.

Talk about a worrying situation, no wonder crews are leaving in droves.