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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 28th Jun 2021, 22:38
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Red 5 - Got it today and must admit I am seriously impressed with the book and David Hill the author. Well researched and despite the various and somewhat complex technical issues involved it is presented in such a way that makes the facts jump off the page. Extremely well done David.

DOF
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Old 29th Jun 2021, 19:51
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An excellent book. Several ‘agencies’ should hang their heads in shame….(IMHO)

Is David still considered Mr Vexatious and on the Whitehall naughty step? Perhaps Tecumseh would know.
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Old 29th Jun 2021, 21:18
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Originally Posted by langleybaston View Post
Am I alone in being a little uneasy about this prosecution? Very difficult to put into words.

Here we have a magnificent world leading British company of undoubted excellence to go through the wringer. As I read the BBC, this is not manslaughter or criminal negligence. We are not talking about a dodgy operation running fun-fair rides, or operating unsafe ferries.

I suppose the most favourable outcome now would be for the fine detail of the problem/ cause to be understood and acted on [although we would hope that was done days after the tragedy], and that any fine was transferred without delay to the victim's family. Any senior employee seen to be negligent should be dealt with appropriately.

Please don't shoot the messenger, I have never sat in a bang seat, but I do grow weary of this liitigious society where every accident has a blame to be attached.
I have sat in bang seats, and share your unease, LB.
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Old 30th Jun 2021, 06:59
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Like most posts on this thread, LB's was made before it was known that MoD concealed the existence of at least twelve RAF training films, imparting the information Martin-Baker were accused of not providing. Nor was it widely appreciated that the Judge, Mrs Justice Carr, actually named in court one MoD recipient. But she had to accept Martin-Baker's guilty plea. (The book explains the process whereby he signed for the information, and it was disseminated within MoD).

The company did not commit manslaughter or criminal negligence. But a prima facie case exists that MoD personnel did, by issuing instructions to technicians NOT to follow Martin-Baker's information, or the technical training provided by the RAF.

The fine detail of the problem was understood, and was dealt with twice in the training films. Also, in the technical publications and training provided by Martin-Baker (until MoD cancelled the contract in 1983). After the accident, MoD even issued a directive that Martin-Baker's information was STILL NOT to be implemented.

In 2018 Jonathan Bayliss was killed at RAF Valley. TWELVE factors in the Cunningham case were repeated. MoD had assured the Coroner in 2014 that they were being, or had been, acted upon. It lied. A recurring theme. And not forgetting that the Cunningham accident was itself a recurrence, repeating the failure that killed Simon Burgess - failure to conduct disturbed systems testing.

And yes OMS, you're regarded as vexatious if you ask questions about this! By both MoD and the legal establishment.
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Old 30th Jun 2021, 10:07
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Sadly ironic that when we had unit seat bays anyone attempting similar sort of work on a installed seat would have most probably faced a tech charge. It most definitely would not be sanctioned. We had a harrier gr7 sat on the ground in the USA for nearly a week so a seat team could come out to change an item that was a much simpler task.

Would like to see the risk register for the removal of seat servicing and support at unit level.

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Old 30th Jun 2021, 10:11
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Got my copy yesterday, superb book, but what an incredible revelation of incompetence and downright dishonesty in both MOD and certain aspects of RAF training or lack of. On page 135 it reveals that only 2 aircrew of 40 questioned knew how to check the top latch was correctly engaged, unbelievable.. That , in my day certainly and should be now, , was one of the simplest but most vital checks on the seat, done carefully each time EVERY time.

Frightening, that training had fallen to this level.

My take is that the prosecution and conviction of MB was a miscarriage of justice.

Mandatory reading for anyone at all interested in this accident or ejection seats in general.
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Old 30th Jun 2021, 11:00
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Retired BA/BY

Would it be possible for you to give us a bit more detail on the claim that so few aircrew knew how to correctly check the top latch?

Thatís a hell of a claim and suggests that either I was the only one who used to teach it properly (which I know for a fact is not the case), that I myself was not teaching it properly (which I very much doubt is the case), that nobody pays any attention to ejection seat briefs (which I very much doubt) or that the author or reader is making incorrect assumptions.

Iím not suggesting that either you or the author are being slanderous in any way. I know you have a particular vested interest in ejection seat safety but I can assure you that in my 22 years of RAF service thus far, everyone I have ever met takes it as seriously as you do. So that claim seems a little off target to me.

The top latch in particular (I assume we are talking about the plunger) is one of the most vital checks and has always been stressed to pilots as such.

BV
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Old 30th Jun 2021, 11:12
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Just to clarify though - that it was not the top latch in the XX177 accident.
On XX177 the scissors shackle had been overtightened which prevented the chute deploying.
The seat pan firing handle was suspected as not being pinned/checked/seated correctly which is what caused the seat to fire due to the SPFH being inadvertantly pulled out of its housing during after start checks.
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Old 30th Jun 2021, 12:28
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Bob,

Please - this is genuinely not an attempt to trip you up or embarrass you, but: would you mind, without looking it up, just articulating what you actually check for with the TLP?
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Old 30th Jun 2021, 13:08
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For those commenting before reading the book, the chapter in question is entitled 'A pattern of behaviour', and discusses the common factors between the Sean Cunningham, Mike Harland and Simon Burgess accidents.

The Top Latch Plunger issue relates to the Harland case, and the relevant extract is:

"The Top Latch Plunger, holding the seat in position until fired, had been incorrectly engaged. The assembly consists of a plunger element and a spring-loaded spigot running through its centre. (Figure 9). At the Inquest, on 19 October 2010, the pilot confirmed aircrew were expected to check this locking mechanism during pre-flight checks. But, he understood it was only necessary to ensure the spigot was correctly aligned. That, he and 40 other civilian and military Tornado aircrew he had canvassed did not know to also check the end of the plunger was flush with its housing. Only two people he asked knew this. But two is enough to indicate the correct instructions were provided by Martin-Baker. (In the same way groundcrew from Lossiemouth and Coningsby knew how to fit the Drogue Shackle nut correctly)".

So, if questioning the statement, might I suggest you speak to the pilot who gave evidence under oath.

The similarity with the Cunningham case is that MoD claimed a lack of information. The 'Figure 9' referred to reproduces a sectioned diagram of the assembly, provided by Martin Baker to MoD. It shows the "correct (plunger fully home)" plunger position, and an "incorrect (plunger not fully home)" position. BV, you may even have used it when training aircrew.

As with the Cunningham case, the book merely reproduces the information MoD says it does not have - sourced directly from MoD documents.

This repeats Chinook ZD576, Nimrod XV230, Hercules XV179, Sea Kings ASaC Mk7, and so on and on.

I say again. MoD lied.

Last edited by tucumseh; 30th Jun 2021 at 13:21.
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Old 30th Jun 2021, 13:25
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Originally Posted by Bob Viking View Post
Would it be possible for you to give us a bit more detail on the claim that so few aircrew knew how to correctly check the top latch?

That’s a hell of a claim and suggests that either I was the only one who used to teach it properly (which I know for a fact is not the case), that I myself was not teaching it properly (which I very much doubt is the case), that nobody pays any attention to ejection seat briefs (which I very much doubt) or that the author or reader is making incorrect assumptions.

I’m not suggesting that either you or the author are being slanderous in any way. I know you have a particular vested interest in ejection seat safety but I can assure you that in my 22 years of RAF service thus far, everyone I have ever met takes it as seriously as you do. So that claim seems a little off target to me.

The top latch in particular (I assume we are talking about the plunger) is one of the most vital checks and has always been stressed to pilots as such.

BV
BV If you properly read what I wrote you would not need to ask the question.

As I said, has been repeated here by Tecumseh , I was quoting what was written on p 135 of the book and I was quite astounded at that statement as I thought EVERY pilot who used ejection seats would correctly check the latch.

I suggest you read it.

Please note the comments on p33 re making the seat safe, pins being replaced AFTER the jet has come to a halt on chocks, engine shutdown, NOT as part of the after landing checks whilst the aircraft is moving.

The book states, not me, that the unsafe seat was not identified by no fewer than 7 individuals on 19 checks !

I seem to remember you were critical of me. advocating this procedure, as was done in my time on 2,3 and 4 seats, in an earlier post.

Last edited by RetiredBA/BY; 30th Jun 2021 at 14:08.
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Old 30th Jun 2021, 16:23
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Further to RetiredBA/BY's post, the other statements he correctly mentions (pins, unsafe seat not identified) were taken from MoD reports.

Bob, I do not doubt that the pilots you taught were attentive and took ejection seat safety seriously. But some very senior officers (and Civilians) demonstrably did not. See dctyke's post, above. If the regulations and instructions had been followed, this accident would not have happened. Who withdrew the wherewithal to satisfy those regulations and instructions? Again, dctyke nails it. What does the risk register (or hazard log, or impact assessment, or Safety Case) say about the decision to withdraw that capability? A rhetorical question - there was no Safety Case. Again, as admitted by MoD. Been there before.
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Old 30th Jun 2021, 20:54
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Questions, questions.

RLE.

It would appear to be cheating now but I could tell you even when drunk that it is Ďspigot in line with the plunger, plunger in line with (or slightly recessed) the housingí. I also fully understand why that is important and I knew it before Mike Harlandís accident.

I would be genuinely shocked if 38/40 of my FJ colleagues honestly did not know that when questioned.

BA/BY

With regards to the pin in whilst taxying thing (I havenít read the book and Iím not likely to, so quoting page numbers wonít help) Iíve never had a problem with it. Clearly some people have and the latest modification to the ejection seat firing handle housing has taken care of that.

Remember that lots of things went wrong for Sean and Iím not going to get drawn into any public conversations about the incident.

Please donít think for one second that ejection seat safety is not taken very seriously nowadays. I can assure you it always has been on every unit that I have served on in three different Air Forces.

BV
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Old 30th Jun 2021, 21:17
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When I was a sqn wpns tm I went through mandatory cockpit ejection seat safety certification check individually with all the aircrew once a year. One of the most emphasised of those checks was the top latch plunger.
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Old 30th Jun 2021, 21:24
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Dctyke

That is still done which is why I am a little sceptical about such a claim.

BV
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Old 1st Jul 2021, 07:06
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Bob Viking / dctyke

What you're actually highlighting and confirming is that, despite correct information and training being provided, initially by Martin-Baker and then MoD/RAF, poor practices were allowed to develop, and were perpetuated by savings at the expense of safety. (The Nimrod Review in a nutshell). Thank you for that support.

I cannot speak for Bob's case, except to reiterate what was claimed at the Inquest. But the excellent training dctyke was obviously given became impossible to implement due to these cuts. In this case, the demise of seat bays combined with Engineering Authorities issuing illegal Routine Technical Instructions. Who met their legal and moral obligations by reporting these violations? To whom, and what was their reaction?

For example, few, if any, at Scampton or Valley would understand that an RTI was strictly prohibited in this case. But they would all know, intuitively, that something was very wrong. Any trained fitter, of any trade, would know not to torque the drogue shackle nut. (Quite apart from the fact Martin-Baker's instructions said DO NOT TORQUE). So why the hell instruct maintainers to do it? And why (apparently) did no-one go back to the Issuing Authority and say THIS IS BOLLOCKS, DID YOU MISS YOUR FIRST DAY'S TRAINING? As the book says, this is akin to a prospective pilot's first lecture on lift.

The Service Inquiry made the ludicrous claim that no basic engineering principle had been breached. Here's one... The effect of friction. That one claim should, in my opinion, prompt the Chief Engineer to launch a review of engineering training, and for the Convening Authority to reconvene the SI, under a trained engineer. Not to mention it is even more exculpatory evidence in the persecution of Martin-Baker.

Despite your reluctance to read the book it Bob, it is the only place you'll find details of how to avoid recurrence, which is something that anyone in the Services and MoD should, I believe, be keen to learn. However, I know the MAA and legal establishment disagree. But I also know from your posts I'm not a lone voice, another claim MoD has made!
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Old 1st Jul 2021, 08:21
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BV :-
I haven’t read the book and I’m not likely to, so quoting page numbers won’t help
Bob, I find your rather dismissive attitude to David Hill's book Red 5 surprising and very much out of character. Presumably it isn't the cost of buying either the Kindle or Paperback editions as both are at a minimal price, and whatever proceeds there are go to charity. I would not have expected a closing of mind from someone who has always been a voice of moderation and authority on this forum. David Hill writes from the knowledge of how the system is supposed to work, how it used to work, but how it stopped working and why. He has been at pain to emphasise that it was deliberately subverted from the very top and, despite the professionalism of those like yourself who strive to maintain standards behind the Station Gates, once dealt the savage cuts in finance and experienced manpower the inevitable spread of unairworthiness throughout the fleets led to the numerous airworthiness related fatal accidents featured in this forum, including of course Sean Cunningham's.

This revised edition is simply the latest offering from him, but all his books are authoritative and based on evidence. He is not about attacking the RAF, or rather what I would call the "real" RAF, ie that which operates from behind those same Station Gates, but against those VSOs that perpetrated this crisis in Air Safety and those who have attempted to cover it up ever since. It cost us the Air Cadet gliders, now reduced to a shadow of their former selves, and our Maritime Patrol capability, again only now being rebuilt at long last. It has cost us losses in life, material, and Air Power. Those like you who serve in the RAF are naturally reluctant to accept that, but all the more reason to read what David Hill says with an open mind. Then decry him if you must, but in all fairness read this book first!

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Old 1st Jul 2021, 08:57
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Some excellent posts here. I share chug's view and that of others. This book is required reading.
I hope the author doesn't mind, but this passage from page 70 stands out....

"Why was MoD signing a report arising from a British Aerospace query? Because Martin-Baker had correctly notified MoD. This is precisely the kind of empirical evidence required by investigators, and again indicative of the lack of depth of all investigations. Martin-Baker were accused of not advising MoD of the issues addressed by this investigation. MoD signed the report. Q.E.D."

That leaves me utterly speechless at the prosecution's gall and Martin-Baker's guilty plea, and despite producing the evidence proving them innocent of the charge, the author doesn't hold back from criticizing them. Their plea, to avoid upsetting MoD (the author directly quotes their lawyers), defeats justice and encourages recurrence. But the really interesting part is towards the end, The HSE investigator should be in the dock. I can't understand why the judge was happy being lied to.

This is a work of major importance. BZ Mr Hill.

Martin
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Old 1st Jul 2021, 09:55
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[QUOTE=Bob Viking;11071126]RLE.



BA/BY

With regards to the pin in whilst taxying thing (I haven’t read the book and I’m not likely to, so quoting page numbers won’t help) I’ve never had a problem with it. Clearly some people have and the latest modification to the ejection seat firing handle housing has taken care of that.

Absolutely incredible that someone like yourself is not reading every word of this excellent book. You might just, might, learn something to your advantage, particularly as you are flying the same type, seat.

So you have no problem inserting pins whilst taxi-ing. Yet. BA never had a gear pin problem till their 787 incident at LHR two weeks ago, very expensive but very fortunately without injury. Their procedures WILL no doubt change after the AAIB conclude their investigations.

I am still at a total loss as to why you guys are installing pins whilst taxiing when such a procedure was an absolute no no, for obvious reasons in the interest of safety as described on p33 of the book, in the MUCH bigger RAF during my time. We were not amateurs and I would argue to any court etc. anywhere, that if our procedures had been practiced there is very good chance that this accident would not have occurred

Apart from essential actions for after landing the only place for eyes is outside the cockpit, particularly if taxiing in a formation. Leave the seat pins til shutdown, when you can give it your full and complete attention and a careful visual check, each time every time.

Buying the book may just be one of your best purchases !

( and just to be clear, I was a. RAF standards QFI and an ejectee, so have a close interest in and some knowledge and experience of these matters)

Last edited by RetiredBA/BY; 1st Jul 2021 at 10:36.
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Old 1st Jul 2021, 11:51
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BA/BY

I know and respect your experience and Iím not trying to pick a fight.

If weíre going to play the willy waving game though I am a CURRENT Hawk QFI with very nearly 3000 hours on Hawks (T1/T2/115/165/166) and have at various times been a standards QFI as well in three different Air Forces so I am hardly an amateur. I do not have direct experience of ejecting though so you definitely trump me there.

Please remember that the report is discussing the Hawk T1 and its ejection seat. The Hawk I currently fly has a much updated seat that does not use the mechanical scissor shackle. The seat pan handle modification also makes it impossible to install the pin in the wrong place.

I know you feel very strongly about installing a pin whilst taxying because of the procedures that were in place when you were flying on bang seats. However, vacating the runway and stopping (that is the current recommended procedure) to install the pin is not inherently unsafe. In fact I would argue that the sooner you can make the seat safe, the better.

I know we can dream up scenarios where a ground ejection during taxy back to dispersal is necessary but personally I would rather take my chances with vacating the aircraft manually once I am at safe taxy speed.

I know we will never agree on this but the current procedures were not dreamed up on a whim and have been subject to extraordinary levels of scrutiny by people with a lot of experience and approved by individuals who would be required to represent themselves in court.

BV
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