Martin Baker to be prosecuted over death of Flt Lt. Sean Cunningham
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Tinribs: Until this accident it still was (I was told). When I left BAE, lots of steps were being made to address this issue too.
A lot of time and effort were finally being applied to this problem which was well known (a tad late in my opinion).
Sadly, most of us who have been/are in the industry (civil or military) could probably point at other 'known' issues - Haddon-Cave all over again.
Sad too that it takes a body count. There are no winners - except perhaps the bean-counters (in the short term).
A lot of time and effort were finally being applied to this problem which was well known (a tad late in my opinion).
Sadly, most of us who have been/are in the industry (civil or military) could probably point at other 'known' issues - Haddon-Cave all over again.
Sad too that it takes a body count. There are no winners - except perhaps the bean-counters (in the short term).
Last edited by Brian W May; 2nd Oct 2016 at 18:11. Reason: Added who I was responding to.
BWM:-
Never was a truer word spoken. This sorry mess was initiated in 1987 when a disastrous short term AMSO policy led directly to the plundering of the previously ring fenced Air Safety budgets. Once started the pillage had to continue. Those who would not obey illegal orders to suborn the regulations had to be got rid of, and with them went the accumulated knowledge and experience of decades. Those engineers were replaced by administrators and soon the corporate memory was wiped completely clean.
Airworthiness is a continuous process. Interrupt it, ignore it, pay lip service to it, and the results are inevitable. 63 lives lost in airworthiness related fatal military air accidents in PPRuNe featured threads alone. MOD's efforts to pin the blame on aircrew, on senior officers, and now on companies, are its desperate attempts to obscure the truth, that all this was caused by the Gross Negligence of certain RAF VSO's, and then covered up by other succeeding RAF VSO's. Quite apart from the price paid in blood and treasure they have dishonoured the Service which has promoted them to such august ranks.
This has to stop. There must be an end to these avoidable tragedies. The MAA and MilAAIB must be made independent of the MOD, and of each other, and the long and painful reform of UK Military Airworthiness set in motion.
Let right be done!
There are no winners - except perhaps the bean-counters (in the short term).
Airworthiness is a continuous process. Interrupt it, ignore it, pay lip service to it, and the results are inevitable. 63 lives lost in airworthiness related fatal military air accidents in PPRuNe featured threads alone. MOD's efforts to pin the blame on aircrew, on senior officers, and now on companies, are its desperate attempts to obscure the truth, that all this was caused by the Gross Negligence of certain RAF VSO's, and then covered up by other succeeding RAF VSO's. Quite apart from the price paid in blood and treasure they have dishonoured the Service which has promoted them to such august ranks.
This has to stop. There must be an end to these avoidable tragedies. The MAA and MilAAIB must be made independent of the MOD, and of each other, and the long and painful reform of UK Military Airworthiness set in motion.
Let right be done!
PPRuNe Person
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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?
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?
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.
longer ron: The Reds do use steps at Scampton; see pic below from the BBC news article reporting Sean's death. Anyway are you suggesting that it is not possible to check whether the seat pin is inserted unless steps are used? I beg to differ - you just need to climb the integral steps and peer over the edge of the cockpit. Otherwise how would anyone (aircrew included) check the seat was safe before standing on it to conduct the rest of the pre-flight checks?
Would be difficult for groundcrew to do a proper check of the SPH from the built in step,the Hawk front seat SPH area is cramped by the Windscreen Arch for a vertical visual check and not sure if that was SOP with the Reds at that time.
Your photo is not conclusive proof that Aircraft Steps were used during the accident a/c start - which is why I asked my question !
Your photo is not conclusive proof that Aircraft Steps were used during the accident a/c start - which is why I asked my question !
I did not really want to get involved in this subject again but I would just say that the technical investigation of this accident was first class and anybody posting on this thread should really read the full report(s) prior to posting.
I would also agree with some previous posters that it had been standard practice for aircrew to 'rattle' the scissors shackle during seat checks right from early days on the Hawk - so the potential problem with the shackle was well known about !
I would also agree with some previous posters that it had been standard practice for aircrew to 'rattle' the scissors shackle during seat checks right from early days on the Hawk - so the potential problem with the shackle was well known about !
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Shackle Rattling
I was the Maint TP at the Canberra MU, I knew the shackle should be slack ,because they said so, many times; but I never understood why.
If I did not know with several tours done on many seats then who would?
I suppose over the years if the significance of an act is not understood then attention to that action will slide
If I did not know with several tours done on many seats then who would?
I suppose over the years if the significance of an act is not understood then attention to that action will slide
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RTI/Hawk/59
Does anyone know if a similar RTI to RTI/Hawk/59 was ever raised for the Mk10 seat fitted to the Tornado? I know that the Tornado's seat has a gas shackle and not a scissor shackle, but the RTI referes to the cross beam which I believe is common to both types of seat.
DV
DV
I suppose over the years if the significance of an act is not understood then attention to that action will slide
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I'll just chuck in a point for discussion, I've only skimmed across the first few pages so I may have missed some bits:
The ALARP (As Low As Reasonably Practical) principle has been the corner stone of safety engineering for decades. The basic outline has been described as the application of more and more mitigations until you reach a point where further mitigation was unjustified on the grounds that implementing the mitigation would not reduce the risk further.
In crude terms, you add more and more mitigations until you reach a point where the risk is acceptable.
ALARP has been replaced with SFAIRP (So Far As Is Reasonably Practicable) sometimes referred to as SFARP. With SFARP the intent is that you start with a list of everything you could do, then discount or remove those mitigations that are not reasonably practicable to implement.
In theory ALARP and SFARP should arrive at the same point, but there is very little significant case law currently available to draw a conclusion. However there are some opinions that you are less likely to be able to prove that you have met SFARP than ALARP, because in the event of being taken to court you (as the defendant) would have to prove that you have indeed considered everything "practicable" and either implemented it or justified why it was not SFARP.
It may be that in this case the HSE are considering that MB did not meet SFARP by not doing everything reasonably practicable, including consulting, communicating and cooperating wit their customers.
The ALARP (As Low As Reasonably Practical) principle has been the corner stone of safety engineering for decades. The basic outline has been described as the application of more and more mitigations until you reach a point where further mitigation was unjustified on the grounds that implementing the mitigation would not reduce the risk further.
In crude terms, you add more and more mitigations until you reach a point where the risk is acceptable.
ALARP has been replaced with SFAIRP (So Far As Is Reasonably Practicable) sometimes referred to as SFARP. With SFARP the intent is that you start with a list of everything you could do, then discount or remove those mitigations that are not reasonably practicable to implement.
In theory ALARP and SFARP should arrive at the same point, but there is very little significant case law currently available to draw a conclusion. However there are some opinions that you are less likely to be able to prove that you have met SFARP than ALARP, because in the event of being taken to court you (as the defendant) would have to prove that you have indeed considered everything "practicable" and either implemented it or justified why it was not SFARP.
It may be that in this case the HSE are considering that MB did not meet SFARP by not doing everything reasonably practicable, including consulting, communicating and cooperating wit their customers.
not reasonably practicable to implement
In this case, even though I've never had dealings with Martin Baker, I find it impossible to conceive of them not fulfilling their contractual obligations. But, while the MoD may have been a customer, how quickly and to what extent does that obligation recede if you're no longer under proper contract? How long do you wait without income before making staff redundant? If or when a contract appears, how long does it take to recruit and retrain staff, and do you still retain corporate memory? Where are the MoD staff whose job it is to monitor and manage this situation? The MoD(PE) section who did this (on avionics) was disbanded in June 1993, after 3 consecutive years of 28% cuts. Within 12 months major contractors, with a better cash flow than Martin Baker, were laying off staff and warning MoD of huge start-up costs should it ever want more work done. Some beancounter would hoover up gongs and awards for reducing in-year expenditure, while everyone else was preparing for a huge bow-wave and financial black hole. My concern today is that Martin Baker don't retain sufficient knowledge to defend themselves.
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Ogre, just to clarify. As I understand it, the Health And Safety At Work Act is written using the "so far as is reasonably practicable" form of words. "As low as reasonably practicable" is the HSE (and safety engineering) preferred translation of the act wording into something a bit more meaningful for engineers. One has not replaced the other.
Additionally the ALARP concept requires that further mitigations are required until the 'cost' is grossly disproportionate to the risk reduction gained. Typically this means that a Court would expect that the cost of further mitigations would be a factor of 3 to 10 times more than the risk reduction (expressed as a cost). Note that the 'cost' might be £s but could just as easily be time or effort expended - its the legal usage of 'cost'.
As you might imagine this use of 'cost' complicates matters for the engineer and the use of £s for fatality is controversial for some people and the Press. A few companies therefore use some form of formal review in the presence of senior engineering staff to explore the whether ALARP can be judged to have been achieved for the hazards with the worst hazard/risk category.
Tuc, its worth saying that while cost is a legitimate consideration for ALARP assessments, affordability is not. The subtlety is sometimes missed.
EAP
Additionally the ALARP concept requires that further mitigations are required until the 'cost' is grossly disproportionate to the risk reduction gained. Typically this means that a Court would expect that the cost of further mitigations would be a factor of 3 to 10 times more than the risk reduction (expressed as a cost). Note that the 'cost' might be £s but could just as easily be time or effort expended - its the legal usage of 'cost'.
As you might imagine this use of 'cost' complicates matters for the engineer and the use of £s for fatality is controversial for some people and the Press. A few companies therefore use some form of formal review in the presence of senior engineering staff to explore the whether ALARP can be judged to have been achieved for the hazards with the worst hazard/risk category.
Tuc, its worth saying that while cost is a legitimate consideration for ALARP assessments, affordability is not. The subtlety is sometimes missed.
EAP
Last edited by EAP86; 10th Oct 2016 at 14:50. Reason: clarification
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EAP86
Perhaps SFARP has not replaced ALARP in the UK, but it has elsewhere. In Australia the new WHS legislation makes a big thing over SFARP, and is leading to a lot of time and effort to prove we have done everything reasonably practicable, with requests for details of what mitigations we didn't implement and why not. There may be an engineering interpretation of the term , but there is also a legal interpretation which concerns me.
I'm glad you brought up grossly disproportionate, I didn't want to mention it originally as it would muddy the waters in terms of how you decide you have reached the ALARP/SFARP point.
There is at least one health and safety legislative act currently in use in the world that defines what "reasonably preacticable" is, and grossly disproportionate is only one of the factors to consider. As for the cost of implementing a mitigation, the insurance industry uses the term "cost of preventing a fatality" which in effect puts a monetary value on a human life.
One side effect of this case will be that companies who produce products (and I do mean anything) will need to spend more time and resources providing evidence that they have met SFARP, so that in the event they are taken to court they have a justification for doing what they did. Not much of an issue for your new smart phone, but aircraft, ships, trains, land vehicles all have a greater potential to cause death and injury.
And don't forget driverless cars!
Perhaps SFARP has not replaced ALARP in the UK, but it has elsewhere. In Australia the new WHS legislation makes a big thing over SFARP, and is leading to a lot of time and effort to prove we have done everything reasonably practicable, with requests for details of what mitigations we didn't implement and why not. There may be an engineering interpretation of the term , but there is also a legal interpretation which concerns me.
I'm glad you brought up grossly disproportionate, I didn't want to mention it originally as it would muddy the waters in terms of how you decide you have reached the ALARP/SFARP point.
There is at least one health and safety legislative act currently in use in the world that defines what "reasonably preacticable" is, and grossly disproportionate is only one of the factors to consider. As for the cost of implementing a mitigation, the insurance industry uses the term "cost of preventing a fatality" which in effect puts a monetary value on a human life.
One side effect of this case will be that companies who produce products (and I do mean anything) will need to spend more time and resources providing evidence that they have met SFARP, so that in the event they are taken to court they have a justification for doing what they did. Not much of an issue for your new smart phone, but aircraft, ships, trains, land vehicles all have a greater potential to cause death and injury.
And don't forget driverless cars!
EAP86
Good answer. Some years ago, during the Nimrod XV230 debates, it was asked what price MoD places on a life. I recall the formal answer was around £4M, which hadn't been adjusted for inflation in about 15 years. This was later reduced to just over £1M, which meant some proposed mitigations were not longer justifiable, in a financial sense. As you say, they were affordable, but didn't pass scrutiny. The problem, of course, is how to prove how many deaths this will prevent. (The Army got sucked down this path in the 90s and 00s, wasting years on studies and trials, while the solution was obvious and soldiers were dying. Government's facile response is "We're aware, we're doing something, these things take time"). It tends to lead to a reactive, not proactive, system; which is more to the liking of MoD and Government. For as long as I can remember, MoD's risk management strategy was "wait to see if it happens, then think about doing something". When something happens, people die.
This case is actually a very good example. How much would it have taken to avoid it? The regs existed which, if followed, would have avoided it. It cost more to not implement them. You can say the same for most accidents discussed here.
Good answer. Some years ago, during the Nimrod XV230 debates, it was asked what price MoD places on a life. I recall the formal answer was around £4M, which hadn't been adjusted for inflation in about 15 years. This was later reduced to just over £1M, which meant some proposed mitigations were not longer justifiable, in a financial sense. As you say, they were affordable, but didn't pass scrutiny. The problem, of course, is how to prove how many deaths this will prevent. (The Army got sucked down this path in the 90s and 00s, wasting years on studies and trials, while the solution was obvious and soldiers were dying. Government's facile response is "We're aware, we're doing something, these things take time"). It tends to lead to a reactive, not proactive, system; which is more to the liking of MoD and Government. For as long as I can remember, MoD's risk management strategy was "wait to see if it happens, then think about doing something". When something happens, people die.
This case is actually a very good example. How much would it have taken to avoid it? The regs existed which, if followed, would have avoided it. It cost more to not implement them. You can say the same for most accidents discussed here.
tuc:-
Indeed it is, not only in the arcane sense of those technically informed, such as yourself, EAP, Ogre, and others posting here, but also of those with power that is unconstrained by such technical expertise or even the basic awareness of the difference between right and wrong. The dismissal of those dedicated engineers who would not bend to illegal orders to suborn the airworthiness regulations and their replacement with those who were ignorant of the regulations and who did as they were told effectively compromised the system to the extent that it became utterly dysfunctional. Thus it has remained, despite the constant reinventing of titles that merely keep the sign-writers busy.
There will be more tragedies, more avoidable deaths, more waste, until the very deliberate damage to the system is repaired. That can only happen after the Military Regulators and Investigators are independent of the MOD and of each other. That can only happen after the RAF 'fesses up to the actions of some of its Air Marshals, and the cover up since by other Air Marshals.
This case is actually a very good example.
There will be more tragedies, more avoidable deaths, more waste, until the very deliberate damage to the system is repaired. That can only happen after the Military Regulators and Investigators are independent of the MOD and of each other. That can only happen after the RAF 'fesses up to the actions of some of its Air Marshals, and the cover up since by other Air Marshals.
That can only happen after the Military Regulators and Investigators are independent of the MOD and of each other.
Chug, you mention this view frequently. I don't agree with you. I think there is now sufficient independence because DG DSA answers directly to the Secretary of State for Defence and not to any military person or authority. The Mil AAIB is now within the Defence AIB and entirely separate from the MAA, albeit both are part of the DSA. And on the certification side, military certification standards must also include consideration of any changes to EASA CS25 standards.
If you compare MAA/DAIB with what happens in UK civil aviation, both the CAA and the AAIB are directed in the same way from DfT. The Chief Inspector of Air Accidents answers directly to SofS for Transport, as does Chief Exec CAA. Why should military air safety be handled differently? Do you think the DfT should change its arrangements as well and, if so, how would you separate the responsibilities? Who should CAA and AAIB answer to if SofS DfT is not sufficiently independent? And at what level is it appropriate for these functions and responsibilities to come together?
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Regarding the shackle, wouldn't you think they'd have fitted a spacer or a sleeve to prevent overtightening.
As in so many things, there has to be a body count. So sad and all to save a groat which has long gone . . .
As in so many things, there has to be a body count. So sad and all to save a groat which has long gone . . .
Fortissimo
I think what Chug is getting at is that the MoD is both operator and judge/jury in its own case. The CAA and AAIB are not. The MAA's "Independence" is moot. MoD variously defines independence as "from line management chain" and "commercially". The MAA has, for example, a raft of RAF officers. Do they now have a different line management chain that does not end with CAS? And are the civilians no longer subject to the Ministerial/Cabinet Office rulings that they can be disciplined for refusing to make a false declaration? (Thus risking up to 2 years imprisonment under the Air Force Act, but 5 years for civilians).
The MAA has yet to acknowledge why it exists. If it did, one might be more relaxed about its status. In 2014, its Technical Director claimed to the press "We've asked some difficult questions. That's why we were created". He couldn't have been more wrong. In fact, unless he's been on another planet for 10 years, he's consciously lying. The MAA was created as a result of (mainly) civilian campaigners asking difficult questions about systemic airworthiness failings and fraud by misrepresentation. The MAA continues to deny this, and its MoD colleagues continue to repeat this mantra.
I think what Chug is getting at is that the MoD is both operator and judge/jury in its own case. The CAA and AAIB are not. The MAA's "Independence" is moot. MoD variously defines independence as "from line management chain" and "commercially". The MAA has, for example, a raft of RAF officers. Do they now have a different line management chain that does not end with CAS? And are the civilians no longer subject to the Ministerial/Cabinet Office rulings that they can be disciplined for refusing to make a false declaration? (Thus risking up to 2 years imprisonment under the Air Force Act, but 5 years for civilians).
The MAA has yet to acknowledge why it exists. If it did, one might be more relaxed about its status. In 2014, its Technical Director claimed to the press "We've asked some difficult questions. That's why we were created". He couldn't have been more wrong. In fact, unless he's been on another planet for 10 years, he's consciously lying. The MAA was created as a result of (mainly) civilian campaigners asking difficult questions about systemic airworthiness failings and fraud by misrepresentation. The MAA continues to deny this, and its MoD colleagues continue to repeat this mantra.