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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 1st Jul 2021, 14:08
  #661 (permalink)  
 
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Originally Posted by Bob Viking

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.

BV

I assume you realise that the existence of the gas shackle is one of the many pieces of evidence that demonstrated MoD and the Health and Safety Executive lied to the court? The HSE claimed Martin-Baker had no understanding of the risk, yet they had designed it out with the gas shackle. We're still waiting to hear from MoD precisely how the risk could remain tolerable and ALARP after 1983, when the decision was made not to fit the gas shackle in Hawk, but put it in (e.g.) Tornado.

Also, we await news of why MoD refused so many times to embody the firing handle shroud.

It is indeed gratifying to see a current pilot so willing to counter MoD and HSE's evidence to the Judge that these two issues were irrelevant, as they were completely divorced from the risks of incorrect strap routing and an over-tight shackle nut and bolt. You would have made an excellent Defence witness, as I suspect you would also have been able to counter the HSE's claim to the Judge that the Mk10 seat was the ONLY one to ever have a scissor shackle. MoD did not demur. But I suspect your career would have suffered!
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Old 2nd Jul 2021, 10:16
  #662 (permalink)  
 
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Originally Posted by Bob Viking
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
No willy waving on my part. The point I was making is that I am not an ď armchair quarter backĒ. You may know, others may not.

If the current SOP is to clear the runway, STOP, and then replace the pins I see no issue there at all, seems perfectly safe and reasonable.

However, if the likely procedure ( inserting pin by feel at 50 Knots on a formation roll out) as suggested in 1.4.2.22 in the service enquiry WAS done, that is totally different and I can think of NO reason for such premature action.I have my views on that based on what was practiced, totally different, during my 12 years of ejection seat occupancy and during which I was the refresher course instructor of several very influential and senior pilots including commandant ( des) of CFS.

None did anything remotely like that.

I rest my case.
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Old 2nd Jul 2021, 11:22
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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.
I am nearly through this excellent book and one of the main points of it seems to be that, above a certain rank, the responsible individuals do not have to represent themselves in court. Their involvement is frequently covered up by omissions and lies. The farce of a trial of Martin Baker is a classic example.

The book also exposes the truth that many safety issues are not "subject to extraordinary levels of scrutiny by people with s lot of experience. It appears that we cannot afford them any more.
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Old 2nd Jul 2021, 12:29
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Originally Posted by pulse1
I am nearly through this excellent book and one of the main points of it seems to be that, above a certain rank, the responsible individuals do not have to represent themselves in court. Their involvement is frequently covered up by omissions and lies. The farce of a trial of Martin Baker is a classic example.

The book also exposes the truth that many safety issues are not "subject to extraordinary levels of scrutiny by people with s lot of experience. It appears that we cannot afford them any more.
The idea that the VSOs responsible do not willingly come to court to explain their policies and actions seems extraordinary. Surely if they are truly leaders they should be be proud of what they do and what they stand for, happy to defend their behaviours. To do otherwise lets the whole organisation down, doesn't it? Certainly not much of a match with the blurbs on their website.

'Cannot afford them' (experience safety people.) Really? That is back to the old saying " If you think safety is expensive, try having an accident."
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Old 2nd Jul 2021, 12:32
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tucemseh,

"Also, we await news of why MoD refused so many times to embody the firing handle shroud."

Back in the day, as an 'end user' I was involved with some trials for potential MODs to the seat after the Sean Cunningham accident. The revised SPFH 'faceplate' was a no-brainer. The shroud was more nuanced. On the Hawk T2, the SPFH is angled forward quite markedy and the proposed shroud denied visual confirmation of the SPFH safety pin status. The only way to check the pin and therefore seat status with the shroud fitted, either sat in the seat or looking in from outside, was to leverage the handle back, quite forcibly. Not a good move if the seat wasn't safe. That problem prevented the immediate fitting of the shroud to the seat in the T2. Whether that is still the case, I cannot say.

BTW, I have ordered the book. I just need Covid restrictions to be relaxed so I can return to Blighty and collect!
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Old 2nd Jul 2021, 13:19
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Double Hush

Many thanks. Apologies if I didn't make it clear, but the 'many times' I mentioned were in the 1980s, at the same time the gas shackle mod was rejected. After the accident, MoD and the HSE claimed that MoD initiated the mod/design as result of Sean 's death. Nothing could be further from the truth.

In 2016, the HSE then argued in court that if it could be shown a modification to the handle could have prevented ejection, then Martin-Baker were guilty of negligence for not having taken such action. This overlooked that Martin-Baker HAD taken action. This wasn't the first or last time the HSE claimed the company could set about modifying aircraft without a by your leave. At no time did MoD demur, so these outright lies became accepted fact, and were later repeated by the BBC in an episode of 'Defenders UK', in which the HSE lied again. The HSE and BBC (and Judge) were in possession of the facts before any of these claims were made. They weren't errors, they were blatant lies.
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Old 2nd Jul 2021, 13:32
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Originally Posted by biscuit74
The idea that the VSOs responsible do not willingly come to court to explain their policies and actions seems extraordinary. Surely if they are truly leaders they should be be proud of what they do and what they stand for, happy to defend their behaviours. To do otherwise lets the whole organisation down, doesn't it? Certainly not much of a match with the blurbs on their website.
Those familiar with the Mull of Kintyre case will recall that MoD successfully argued a legal point that if the authors of 'evidence' or claims were not in court, then their work could not be discussed. MoD then prohibited the very senior officers involved (Wratten, Day, Graydon, etc.) from appearing at the Fatal Accident Inquiry. Some years later, Wratten claimed to Jeremy Paxman on Newsnight that Sheriff Sir Stephen Young 'rejected the option of calling my colleagues and I to give evidence. One has to ask why (he) pursued such a course of action'.
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Old 2nd Jul 2021, 16:31
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Shackle use

Having been a user of shackles since my ATC gliding days (and subsequent marine use) I awaited the 'book' with keen interest to see how this simple 'connecter' fitted in with a high tech escape system.
The answer was simple there was a requirement to connect a rope type end to a metal fitting.(in gliding usually to a weak link assembly) (in marine use a rope to a chain). In both cases the 'pin' is load bearing and the nut stops the pin working loose and falling out. Frequently the pins have 'eyes' which can be wire locked rather than a nut. In both cases shackle deformity can occur when overtightened (mainly due to thread wear). In a case where a shackle gets used on to a more technical fitting and a constant gap must be retained it is common practice to use a internal pin sleeve or spacer that prevents inadvertent gap closure. Was / is there a reason this is not common practice on the seat application or was the requirement for a new pin and nut deemed a reasonable alternative. On the basis of cost and the low number of times this was required it seems incredible that anything else was even considered for such an important component.
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Old 2nd Jul 2021, 17:58
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Pobjoy

Your question was asked and debated here when the SI report became available. As Martin-Baker chose not to defend themselves (in order to protect MoD) there was no opportunity to ask. I’m sure it would have come up in court during what was to have been a six-week trial.

So, all that can be said (unless someone involved decades ago wants to come forward) is that the shackle bolt and nut arrangement was deemed to be the engineering design solution, and this was accepted by MoD. The type of bolt changed in the Mk9 seat, but the fitting instruction to MoD remained the same. ‘Tighten the nut until contact is made with the Drogue Shackle. Do not torque’.

This is the information Martin-Baker were fined £1.1M for not providing. MoD’s APs and Martin-Baker manuals from the 50s - 90s containing it were provided to the court and HSE. So too the RAF training films clearly showing the final test that was omitted. So too witness evidence from the head of Tech Pubs in MoD. The HSE simply told the Judge the films were ‘irrelevant’, and flatly denied the existence of the APs and manuals that were provided to both it and the Judge.

Following these instructions would prevent over-tightening and deformity of the shackle. Instead, the nut was over-tightened to such a degree the bolt was bent and new thread cut.

The question then is why, after the accident, did MoD re-issue its instruction to torque the nut to 50 lbf-in; yet again completely ignoring the instructions from Martin-Baker.

Of course, the main question is why in situ servicing was being carried out when the manuals and APs unambiguously said ‘Remove seat from aircraft’. This meant a false declaration was made that the seat was serviceable, because its serviceability could not be verified. Someone gambled when issuing the order not to follow Martin-Baker’s instructions. He lost, and Sean Cunningham died. As dctyke said earlier, we'd all love to see the risk assessment and justification.
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Old 2nd Jul 2021, 19:17
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The Book

I have obviously been too dismissive of the book in question. That was not actually my intention.

I just meant Iím not in a position to read it right now. Iím sure it is a good read and a valuable tome.

I should also point out I havenít flown the Hawk T1 for over ten years so I am not so concerned by T1 procedures.

The Hawk T2, with the SPFH shroud and the pins caption along with the gas system, addresses most of the issues being discussed here.

It is also worth remembering I am an operator not a policy man and in-depth discussions of airworthiness are not my area of expertise. I can assure you though that if I was concerned about the safety of my aircraft I would not strap into it. Thus far that has not been a problem.

BV
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Old 2nd Jul 2021, 19:46
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TUC Thanks for that, I assume that 'normal' or good practice would require a new nut and bolt fitted as directed and then checked for free movement. hardly a difficult operation and seemingly in the general scheme of things not expensive for what it does. I can see that in place seat servicing would be a real loss of good practice, and also a loss of a good opportunity for a loose article check at the same time. Considering the location of the only operating handle being low down in a restrictive place that itself makes a cogent inspection difficult in situ. With that mind set running the show it beggars belief that no one saw a big red light and flagged up what was quite obviously a dangerous practice for such a complex piece of safety equipment. No wonder they b..... up the glider fleet.
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Old 2nd Jul 2021, 20:56
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BV :-
It is also worth remembering I am an operator not a policy man and in-depth discussions of airworthiness are not my area of expertise. I can assure you though that if I was concerned about the safety of my aircraft I would not strap into it. Thus far that has not been a problem.
And there in a nutshell is the problem. Let me add immediately that I shared that same attitude back when. The difference is that I was fortunate to have served when airworthiness was run by the experts that have since been replaced by placemen, and under an RAF leadership that respected those experts and took their advice. I would further add that it was only after I retired that I learned about airworthiness and how the lack of it in UK Military Aviation has caused very many deaths and goes on doing so. I learned about it here, in this very forum. I learned about it from tucumseh and other experienced engineers who have testified here about the monstrous attack on UK Military Air Safety by RAF VSOs and of the cover up of their actions since by other RAF VSOs. So you are not alone by any means Bob.

However, the difference is that my good fortune meant that airworthiness related accidents were few and when they happened immediate remedial action was taken. The best example I can think of was the grounding of the Hastings fleet (some 80 aircraft around the world) following the crash of Hastings TG577 after take off from Abingdon that killed all 41 on board. The failure was discovered by the BoI, and subsequent checks made immediately resulted in the fleet grounded wherever they were. Because proper records had been kept airworthiness was regained slowly as rectification teams completed a complex repair including of course the two bolts that had failed (yes bolts again!). Still the penny didn't drop and I thought of it in terms of serviceability with no inkling of the difference with airworthiness. Civil aviation is no different, I spent more years with the airlines than with the RAF and still blissfully ignorant. If anyone thought about it at all, airworthiness was for the boffins and 'policy makers' as you call them. Fine if they are up to the job and not undermining it to make savings at the cost of safety!

I would respectfully suggest that you start worrying now about the safety of the aircraft you strap into and read Red5 ASAP!
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Old 3rd Jul 2021, 05:44
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Originally Posted by POBJOY
TUC Thanks for that, I assume that 'normal' or good practice would require a new nut and bolt fitted as directed and then checked for free movement. hardly a difficult operation and seemingly in the general scheme of things not expensive for what it does. I can see that in place seat servicing would be a real loss of good practice, and also a loss of a good opportunity for a loose article check at the same time. Considering the location of the only operating handle being low down in a restrictive place that itself makes a cogent inspection difficult in situ. With that mind set running the show it beggars belief that no one saw a big red light and flagged up what was quite obviously a dangerous practice for such a complex piece of safety equipment. No wonder they b..... up the glider fleet.
There's a few separate issues there.

Yes, a new nut and bolt is required every time the Drogue Shackle assembly is dismantled. MoD's report did not address this, and the Routine Technical Instruction being followed at the time does not mention it. The proper assembly instructions (not the illegal RTI) say it is to be assembled in the parachute bay as part of the duplex drogue assembly, which is later fitted to the seat in the seat bay. At that point any jamming or resistance would be obvious, as two checks are required to ensure the shackles can freely disengage. AND THEN ARE NOT TO BE DISTURBED. If they are, then you start again. Yep, it's hassle, but its an escape system that is only required to work once. If you get it wrong, someone dies. But it appears someone spotted an opportunity to save money by eliminating that hassle, without thinking through the impact. I cannot speak for Martin-Baker, but I understand they expressed grave concern at this not-so-cunning plan. So too did MoD armourers. But there's a certain type of person in MoD who sees this as the company being bolshie and awkward, that MoD knows best. Nope, they're satisfying legal obligations.

A free movement check is carried out by pilots, but it gives false confidence. The shackle lugs can be pinched by over-tightening which (as illustrated by the SI in an image of the XX177 shackle), but when this happens the lug faces are no longer parallel. This can allow free movement at the bolt, but not at the ends of the lugs. The effect is variable, and in this case the SI calculated a speed of 50kts would be required to overcome this resistance. It follows that it is likely the problem had occurred before, but only manifested itself when the seat was required at the extreme of its design envelope. (Zero-Zero). Hence, the instruction that the nut just touches the shackle when attached. That eliminates any problems caused by slight tolerance differences in bolt lengths and lug gap.

The handle issue was addressed very well by the SI, who confirmed that the seat height mechanism was required to be motored to the top after use, to allow easier visibility of the handle/pin. However, it reported that the Red Arrows maintainers had been instructed to leave it as is; the implication being this was to shave seconds off a start-up regime, which the Panel said was shorter than normal for other Hawks. I know nothing about Hawk operations, so cannot comment.

My last comment actually highlights one of the main errors made by the HSE and Judge (and MoD in general). I've never been in or worked on a Hawk. But that doesn't stop me understanding basic fitting practices taught when a sprog. Or prevent me from reading and understanding the manuals and APs (which are both excellent). The Judge rejected expert evidence from a highly qualified mechanical engineer on the basis he was not an aviation engineer. As you rightly said Pobjoy, the basics apply to other domains, such as marine engineering. Similarly, the HSE denied that the scissor shackle assembly was in any other seat, because these other seats pre-dated Hawk. A 2 year old can destroy that logic, but.... Similarly, it said information relating to previous Marks of seat was irrelevant, because they were not Mk10s. The fact that the many parts of the design remained the same was also irrelevant - although in this case the HSE went further and denied the scissor shackle was in any other seat. The Judge confirmed it WAS, since 1952, but the HSE just ignored her and continued with its claims even after the trial. What am I saying? The HSE was incompetent, and actively misled the courts and family. MoD was complicit, as it knew this and said nothing.

Last edited by tucumseh; 3rd Jul 2021 at 09:45.
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Old 3rd Sep 2021, 11:59
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A fully revised Kindle version of Red 5 is now out containing new evidence dutifully ignored by those responsible for Military Air Safety. I can do no better than quote the blurb on the Amazon site :-

Revised and updated, September 2021. Includes and discusses new images and information from the investigation, which MoD and HSE withheld from the courts and family.
This is a story of unrelenting misconduct and injustice. Martin-Baker, designers of the world’s best escape system, were prosecuted for not providing information they had already supplied many times, but the Ministry of Defence instructed its engineers not to use. Bizarrely, the Judge named an MoD recipient in court. Applying this information would have saved Sean Cunningham’s life.
The Health and Safety Executive and Lincolnshire Police did not evaluate verbal, written and video evidence proving the allegation false. The Judge and Coroner were misled. This subversion of the judicial system has placed military aircrew, passengers and the public at greater risk.
Also discussed is post-trial misconduct by the HSE and BBC; linkages to the Shoreham Air Display accident, in which the Air Accidents Investigation Branch confirmed MoD had the information necessary to avoid the death of Sean Cunningham; and an analysis of the Service Inquiry report into the death of Corporal Jonathan Bayliss, passenger in a Red Arrows Hawk which crashed in March 2018; revealing twelve common factors with the death of Sean Cunningham.
All proceeds to charity.
RED 5: An investigation into the death of Flight Lieutenant Sean Cunningham eBook : Hill, David: Amazon.co.uk: Books RED 5: An investigation into the death of Flight Lieutenant Sean Cunningham eBook : Hill, David: Amazon.co.uk: Books

Note, if you don't own a Kindle reader, you can still read Kindle books on your PC (other OS provided for also) by downloading the free Amazon App :-

Amazon.co.uk : kindle app for pc Amazon.co.uk : kindle app for pc
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Old 7th Sep 2021, 17:50
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Just now read the update on this on my Kindle.
I submit that it is worth reading as a part of this author's ongoing campaign over several years.
I would savour any qualified opinion on these cases cited..
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Old 7th Sep 2021, 20:23
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So can Martin Baker not now appeal as a miscarriage of justice has been carried out due to evidence being withheld from the court.

Have they now not got sufficient evidence to counter sue the MOD and have their fine returned and claim for damages to their reputation?

Personally I would like to see senior officers involved in both the cover up and withholding information from the courts in the dock, because until they become personally culpable, nothing will change.
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Old 7th Sep 2021, 20:44
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There may be technical reasons that I'm unaware of but, as a licenced aircraft engineer, I find it hard to understand why servicing instructions (or common sense) would stipulate pinching a shackle connection. It defies normal engineering practices. On publicised evidence it seems to me also that Martin Baker has been penalised for a servicing error that they're not responsible for.
I'm open to rebuke.
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Old 7th Sep 2021, 21:55
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No trial, therefore no evidence ......

...
My understanding is that Martin Baker already had all the evidence we are discussing and still chose inexplicably, at the last minute, to plead guilty. As a result there was no trial as such.

Charges read, guilty plea entered, possible statements in mitigation, punishment administered, end of.
Appeal against their own fully informed guilty plea ? .... Self-inflicted injury, m'lady.

Note also that the intended judge was replaced late on in the proceedings.

Pleading guilty prevents a full trial, at which there was a good chance all the real evidence might have been revealed. Who knows where that might have lead, given that a couple of years earlier some authority stated that there would be no prosecution (of anyone)

LFH
...
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Old 7th Sep 2021, 22:17
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Originally Posted by stevef
There may be technical reasons that I'm unaware of but, as a licenced aircraft engineer, I find it hard to understand why servicing instructions (or common sense) would stipulate pinching a shackle connection. It defies normal engineering practices. On publicised evidence it seems to me also that Martin Baker has been penalised for a servicing error that they're not responsible for.
I'm open to rebuke.
As another LAE I totally agree with you. And that’s where the military fall down hands over feet, as a licensed engineer your word is more or less final, you cannot and should not be coerced into signing for or carrying out anything you deem dangerous or unsafe and you would consult with the manufacturer and follow their recommendations as you would carry the can.

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Old 8th Sep 2021, 06:14
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Nutloose

Regarding an appeal, Martin-Baker pleaded guilty, and their reason is given in the book. (And also the reason given by their solicitors, which is slightly different). Lincs Police and the HSE have both refused to assess the verbal, written and video evidence that M-B were innocent of the charge.

As the book says, perhaps the most bizarre aspect of the case is that M-B were accused of not providing information to MoD, and the Judge named an MoD recipient in court. The book explains the process, and why the named person was the correct person to have been informed. The Judge gave SIX other reasons in her remarks why M-B were not guilty, but had to accept the plea. She admitted this caused her 'great difficulty'.

To reiterate, all proceeds go to charity.
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