Martin Baker to be prosecuted over death of Flt Lt. Sean Cunningham
I always did replace them
Just digressing a little:
NTSB: High speed, worn parts led to deadly Reno Air Races crash - CNN.com
" the main culprits, according to the NTSB, were several lock nuts on the left trim tab - a aerodynamic surface on the horizontal part of the plane's tail, nuts that had not been replaced for at least 26 years".
NTSB: High speed, worn parts led to deadly Reno Air Races crash - CNN.com
" the main culprits, according to the NTSB, were several lock nuts on the left trim tab - a aerodynamic surface on the horizontal part of the plane's tail, nuts that had not been replaced for at least 26 years".
An aspect of this tragedy which seem to have attracted few comments is the fact that the chain of events which led to the accidental activation of the seat began as a result of the aircraft being flown with one of the groin straps through the seat pan firing handle. Given the consequences in the event of an ejection, it is to be hoped that this is a highly unusual occurrence, but coupled with the ease with which the safety pin can be fitted incorrectly, it would place quite a premium on much greater care around entry and exit procedures.
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Yes pulse they were nylocks
http://www.ntsb.gov/investigations/A...s/AAB1201.aspx
Totally agree Falcon, but it is the nature of the beast that to save lives there unfortunately the design has risks involved. As for greater awareness I agree again, though unfortunately as in all things, familiarity can and does breed complacency.
It has been a long time since I worked on them, but I seem to remember the L39 also had switches in the in the nosebay that would disarm the seats and make them safe as a back up to the normal seat safety features, OK unless they forget to be set to them to armed that is.
http://www.ntsb.gov/investigations/A...s/AAB1201.aspx
Totally agree Falcon, but it is the nature of the beast that to save lives there unfortunately the design has risks involved. As for greater awareness I agree again, though unfortunately as in all things, familiarity can and does breed complacency.
It has been a long time since I worked on them, but I seem to remember the L39 also had switches in the in the nosebay that would disarm the seats and make them safe as a back up to the normal seat safety features, OK unless they forget to be set to them to armed that is.
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It surely should be evident that one should not 'Pinch' fork ends, or similar structures where freedom of movement is critical. Shouldered bolts being the norm to prevent this, however if not possible, the 'Feeler gauge gap' being blindingly obvious.
I was not an armourer, many other critical bolts on aircraft though.
The very complex 'Top down' management seems to think that the guy on the 'Coal face' should be dismissed if they have concerns.
I remember pilots checking for a loose fit on the shackle, basic stuff really & not really all this 'Enormous paper work trail' that people talk about.
Just an ex liney, take that for what you will.
I was not an armourer, many other critical bolts on aircraft though.
The very complex 'Top down' management seems to think that the guy on the 'Coal face' should be dismissed if they have concerns.
I remember pilots checking for a loose fit on the shackle, basic stuff really & not really all this 'Enormous paper work trail' that people talk about.
Just an ex liney, take that for what you will.
Originally Posted by falcon900
An aspect of this tragedy which seem to have attracted few comments... would place quite a premium on much greater care around entry and exit procedures.
I remember pilots checking for a loose fit on the shackle, basic stuff really
But the "enormous paper trail" is what allows you to identify where the breakdown took place. The Secretary of State also requires it before allowing the aircraft to be flown. There has clearly been multiple breakdowns and that should concern everyone, because the system is designed to withstand failures (checks, double checks, defences in depth). THAT is where senior staff never allow inquiries to go.
Thanks Easy Street. I have read the SI report, and was struck that I have read similar comments about unit culture in more than one contemporary SI report, which is another strand of concern, but what I was getting at with my original post is that whilst there is much discussion on here of the shackle/bolt aspect, and the contractual/safety case aspect, the fact that an experienced pilot can go flying with a crotch strap through the ejector handle is astonishing to the casual observer, and yet seems to have passed on this forum more or less without comment.
I am also struck that the issue of the safety pin being inserted with the handle in an unsafe position seems to be presented in the SI as new news. Call me cynical, but are we asked to believe that in the many thousands of Hawk operating cycles, this has never happened before, or has, but was never noticed? Given the location of the pin, it seems obvious that the pilot would find it difficult to spot the error, but ground crew are in a much better position to do so, and I find it hard to believe there were not instances in the past when they did.
I am also struck that the issue of the safety pin being inserted with the handle in an unsafe position seems to be presented in the SI as new news. Call me cynical, but are we asked to believe that in the many thousands of Hawk operating cycles, this has never happened before, or has, but was never noticed? Given the location of the pin, it seems obvious that the pilot would find it difficult to spot the error, but ground crew are in a much better position to do so, and I find it hard to believe there were not instances in the past when they did.
1. The MAA definition of 'Cause' is "the event that led directly to the accident".
2. In my view, the 'accident' was the death of the pilot. He should have survived this ejection - the MAA report says so. Had he survived, this would not have been an accident, probably only an incident.
3. In my view, the 'event' that led directly to the pilot's death was the failure of the drogue shackle to operate correctly. Not, in my view, the inadvertent operation of the seat pan handle.
2. In my view, the 'accident' was the death of the pilot. He should have survived this ejection - the MAA report says so. Had he survived, this would not have been an accident, probably only an incident.
3. In my view, the 'event' that led directly to the pilot's death was the failure of the drogue shackle to operate correctly. Not, in my view, the inadvertent operation of the seat pan handle.
1) The cause of the accident will be whatever precipitated my departure from the road
2) The cause of death will be 'blunt force trauma' after hitting the tree, and
3) A contributory factor (to death) will be the failure of the seatbelt to perform its designed function due to incorrect installation
Surely that analogy holds for this tragic case?
Last edited by 212man; 1st Oct 2016 at 12:41.
I'll defer to experts but the obvious difference is that in the hawk there is a device that is meant to prevent the blunt force trauma after you exit the windscreen. And does there have to be a single "event"? And does this matter when some clown signed off the release with no safety case? Over to the MAA to say how this was missed ........
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The reality is that the RAF operated this aircraft/ejection seat combination for nearly 40 years before the accident occurred, and during that time there were successful ejections from RAF Hawks, so it seems unlikely that the failings were due to unfamiliarity or design flaws. Somewhere along those years personnel 'lost' their full understanding of operational and maintenance procedures. When, or if, changes were introduced processes should have been in place to review and understand revisions so that any re-training was effective and new requirements were safely applied.
I did ask about the mod state of the "fleet" but the answer was vaguely close to maybe so was both meaningless and annoyingly insubstantial, on the topic of nuts and bolts the snco plumber commented that the DAP says "tighten" and as far as he would be concerned that meant "tighten" properly.
So there's your proof, technical ability reduced to lowest common denominator on the alter of budget reduction.
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But Dervish, that is assuming they knew there was a problem before the incident, surely they can only be culpable if they did.
Precisely, the term tighten means you would run the nut down the bolt until resistance is felt, you would not tighten a bolt and stop short of the shackle or short of when the nut becomes thread bound, the failing is in the terminology of what is required.
Everyone keeps mentioning shouldered bolts or introducing feeler gauges as the solution, well as we have discussed a shouldered bolt may or may not have strength or clearance issues, the simplest solution would have been to replace the existing bolt with one with a longer shank, thus retaining the diameter ( and strength ) of the current item but making it impossible to over tighten the nut or pinch the shackle by the simple fact the nut will become threadbound before it reaches that point.
..
On the topic of nuts and bolts the snco plumber commented that the DAP says "tighten" and as far as he would be concerned that meant "tighten" properly.
Everyone keeps mentioning shouldered bolts or introducing feeler gauges as the solution, well as we have discussed a shouldered bolt may or may not have strength or clearance issues, the simplest solution would have been to replace the existing bolt with one with a longer shank, thus retaining the diameter ( and strength ) of the current item but making it impossible to over tighten the nut or pinch the shackle by the simple fact the nut will become threadbound before it reaches that point.
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Last edited by NutLoose; 1st Oct 2016 at 14:30.
The MAA were around for 20 months before the accident and claimed it had all the PTs audited. Even if they used a tickbox sheet, surely the cross in the box would fail the PT?
We went through all the RTA analogies on the Mull thread (usually to support the MOD/RAF/RO's finding of pilot Gross Negligence) and look how that turned out. As in that case this outcome will be determined elsewhere.
MBA are simply the latest scapegoats for the Gross Negligence of certain RAF VSOs and the cover up of that by other RAF VSOs. At the moment the HSE would appear to need convincing of that, so perhaps MBA should convince someone else, then they could convince HSE...
Meanwhile the usual stove piping will continue, no doubt.
MBA are simply the latest scapegoats for the Gross Negligence of certain RAF VSOs and the cover up of that by other RAF VSOs. At the moment the HSE would appear to need convincing of that, so perhaps MBA should convince someone else, then they could convince HSE...
Meanwhile the usual stove piping will continue, no doubt.
The Service Inquiry only states the servicing information, from 1991, could not be found. At the Inquest, this morphed into “Was not provided by Martin Baker”; yet no evidence was presented either way. I'd be surprised if the HSE and Martin Baker had not spotted this hole in the evidence trail. So, either this does not relate to the charge, or the hole has somehow been filled in. If the latter, why have we not heard of it, for example via a reconvened SI?
I say again, something is going on here. This case shares many similarities with the likes of Chinook, Nimrod, Hercules, etc. (systemic failings) but in those cases the HSE refused to get involved and MoD was permitted to judge its own case (and still is). This time the end game is very different. Now, MoD is (or should be) a witness in court of law, which it will find more difficult to influence. I can't imagine it is happy.
I say again, something is going on here. This case shares many similarities with the likes of Chinook, Nimrod, Hercules, etc. (systemic failings) but in those cases the HSE refused to get involved and MoD was permitted to judge its own case (and still is). This time the end game is very different. Now, MoD is (or should be) a witness in court of law, which it will find more difficult to influence. I can't imagine it is happy.
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Surely, if M-B had known that the RAF would be undoing and retightening that bolt so often, they'd have taken a simple engineering step to prevent the shackle being pinched?
They probably thought that this piece would remain untouched- like a great many assemblies on their seats- throughout the life of the seat. And if anybody WAS going to mess with it, it would be in a seat shop or at their factory.
They probably thought that this piece would remain untouched- like a great many assemblies on their seats- throughout the life of the seat. And if anybody WAS going to mess with it, it would be in a seat shop or at their factory.
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Pins in?
It is some years now but!
As I recall with the Mk 10 seat if the seat pan handle was slightly dislodged it was possible to insert the pin through the seat aperture passing not through but under the handle leaving the handle free to operate
Maybe that got fixed with the arrival of the new larger floppy handles
As I recall with the Mk 10 seat if the seat pan handle was slightly dislodged it was possible to insert the pin through the seat aperture passing not through but under the handle leaving the handle free to operate
Maybe that got fixed with the arrival of the new larger floppy handles
Surely, if M-B had known that the RAF would be undoing and retightening that bolt so often, they'd have taken a simple engineering step to prevent the shackle being pinched?
An RTI is only permitted if the Design Authorities (Martin Baker and BAeS) do not need to be involved in any way whatsoever. A 50 hourly regime on a safety critical escape system most definitely does not fall into this category. Therefore, it is unlikely Martin Baker knew of the RTI, or if they did know they were excluded from the process. As I mentioned before, this has resonance with the illegal Servicing Instruction issued by Odiham on Chinook HC Mk2 and was in all likelihood considered necessary by one part of MoD because another part had cut funding, thus preventing Martin Baker being involved.
If any action connected with this RTI forms part of the HSE's case, then all Martin Baker need do is table the RTI and demand that the signatory be a witness, to explain himself.